Monday, 23 June 2008

On Blaming

‘Harold Hughes, the political Godfather of the modern alcoholism treatment system, often noted that alcoholism was the only disorder in which the patient was blamed when treatment failed. Alcoholics and other addicts have suffered, not only as a result of poorly developed and at times harmful treatment technology, but also through being blamed for their failure to respond to such technology. For decades many addicts have been subjected to treatment interventions that had almost no likelihood of success; And when that success has indeed failed to materialize, the source of that failure has been attributed, not to the intervention, but to the addicts’ recalcitrance and lack of motivation. The issue is, not just that such mismatches do not work, but that such mismatches generate their own iatrogenic effects via increased client passivity, helplessness, hopelessness and dependence. Blaming protects the service provider and the service institution at the expense of the addicted client and his or her family. Defining failure at the personal level can also mask broader failures of social policy.’

William L White in ‘Slaying the Dragon: The History of Addiction Treatment and Recovery in America’ (1998), pp 331.


tim1leg said...

So the blame game it is then, heres my take on it. The problems are listed in no particular order.

The problems.

Badly organised services and doctors that lack appropriate training, systems that are set up to treat addicts are inefficient and laughable considering two thirds of all people arrested test positive for one or more illegal drugs,nearly half of those, have been taking heroin or cocaine.

Waiting lists and the current pattern of service means that too many drug users still struggle to get the help they need, when they need it.

Lack of expertise, of what recovery is and how to get it, high workloads and limited care management mean clients are often not followed up.

Then we have problems that stem from the fact that poor links exist between different agencies such as mental health teams and prisons. Doctors shy away from providing specialist help because they lack the expertise and support.

Under investment in the local services and a "fragmented" approach to buying-in the "right treatment".

Trapped in a cycle of dependency and drug-related crime.

Those with "complex needs" struggle most to get help. The number of people become addicted to drugs is rising and so is the cost of treating them.

Inconsistent standards of care all contribute to a system which can be extremely painful for already vulnerable addicts and their families in need of help.

The current addiction workforce ill equipped to deal with the ever changing UK drug situation.

Please dont assume IM BLAMING, im just listing some of the arguments I hear regularly that I agree with. haha.

Seriously the tendency to blame the system is a convenient way of leaving no one accountable. Those who offer this argument can sound wise without having to grapple with the specifics of any piece of legislation. There is the unspoken assumption that wisdom always lies in the political middle.
Seriously !
There are many more problems as Im sure we all know, but see me Im part of the solution I am in that I know what the real problems are and essentially Im not adding to them or pushing any agendas to directly profit from, how about you?

Anonymous said...

Dear David,

I would agree that their is a culture exisiting or rather persisting within the NHS, NGO's, the Press, and others, including users, that seeks to attribute the 'failure' of certain treatment modalities, notably those orientated towards 'abstinance', to the Patient as opposed to questioning if the treatment modality & objectives, let alone 'conduct'. Terms such as 'recividist', non compliance, lack of moral fibre, character, will power, etc, are deployed rather than the clinician and/or partizan lobbyist confornt the far more chalenging issue posed by the question "why did my treatment fail this patient".

Too often realistic treatment goals, procedure and the definition of 'recovery' are defined by ideolougues, vested interest groups, belief based sytems & NGO's, coercion,local practices ,inherited clinical/moral values, let alone the dominant political order prevalant at any gien time.

As for the individual patient, empowerment through knowledge to both participate & determine, often through trial & error, that best meets their needs and determines the form that recoery means and will take for them.

Long term, life long as required, pharmacolicaly supported recovery (eg agonist maintenance, etc) is and should be accpeted by all, gien the over whelming evidence base, as legitimate form of recoery, in & off itself. For many patients this is not only a form of reducing harm, it is also a means of managing chronic dependence and endorphin dysfunction,etc.

For others in this patient cohort abstinance or semi abstinance is a legitimate personal goal and should be afforded best practice, well resourced funding, support & evidence based guidance.

However, it must be accpeted that abstinance is not a possible, desireable nor achievable goal for many, notably, long term, users.

Further,why do many of the 'New Abstentionists' have no objection to, for example, the long term use of SSRI's for the management of long term abstinance syndrome.

Those of us prescribed SSRI's hae found we were sold a quack medication that provides short term benefits but creates long term dependence. At least we know opioids to be relatively benign
when used appropiatly in the management of opioid dependence/endorphin dysfunction & it's symptoms.

Further too many of the 'New Abs' lobby fail to understand the significant distinction that must be made between 'addiction', a construct of certain psychological/
social, moral, behavoural & 'self interested'political opportunists.

Where as 'dependence' is a medicaly, scientificaly, 'provable
condition determined by patient presentation, tests & the evidence base.

The former (addiction)legitmises and equalises the condition of 'chocaholics' 'shopaholics',
'Sex Addicts'with "heroin addicts', 'alcoholics'in such a manner as to render the term addiction' virtually useless or at least wide open to abuse by those with a vested intrest in the 'addiction treatment industry', which, let's be honest, turns a good profit and has nothing but 'good news' for anxious carers and parents who, seeking a 'cure'for their loved one
are uncriticaly acceptive of anything that promises what they (as opposed to the user) want to hear & believe

That this may prove a life long condition is something that many are resistant too or reluctant to accept as it challenges their desires and recieved wisdom.
Much of it deried from the press & related media that continue to promote an abstinance based agenda.

Sadly, Users are themselves not immune to this 'conditioning' and the belief systems, guilt & self blame it can engender.

Often it can result in users entering and planning treatment basing their 'choices' (if aailable)on recieved wisdom & other prejudiced sources of information as opposed to real wisdom, knowledge & understanding of what evidence their chosen treatment goals and pathways are predicated on.

Real choice must be based upon real evidence, wisdom & knowledge.

Further, no user should be taught or told to expect over night 'miracles' whether from AMT or Abstinance.

Lets not kid ourselves or anyone else, Abstinance based and targeted
'treatment'/ ideology has ruled the roost in the UK since the Brain 2 report in 69 & Harm Reduction / MMT has only been rendered widely accesable since the NTA and Users started to question prevalant & largely in-effective practice that had become entrenched within all segments of the NHS.

Indeed the architects and the enforcers of such belief based practices remain entrenched within treatment provision, it is easy to simulate conformity with the new 'treatment order' whilst doing all one can to undermine it.

Given my national perspective, albeit I am now retired due to ME/CFS,I was privelaged to gain a unique insight into the experience of users, patients, carers & treatment providers across the UK.
This included patients seeking well supported , well managed 'withdrawal' plus longer term abstiance as well as users/patients seeking Agonist based treatment & recovery in and of itself.

One issue that was clearly evident was the persistant and contuing resistance to NTA Guidance, user/patient empowerment, Maintenance Treatment & it's recognition as a form of Recovery
"in and of itself"(Paul Hayes circa 2002?)

It is high time that those who truly seek to help users in the chaos of 'addiction' stabilise and understand the nature of 'dependence and are, without coercion, are informed and empowered to choose and if needs be choose again, & again, the form, mode and nature of 'recovery' that best suit's them as individuals.

Long term, life long if needed, agonist & partial agonist predicated recovery must be legitimised and it must be accepted and legitimised by those who belive & abstinance as the sole form of 'legitimate recovery'.

Without mutuality of recognition, acceptance, and respect, I fear that lobbyists will continue to do very well singing a song that is populist nonscience that funders want to hear, thankyou very much.
With funders largesse given accordingly.

Whilst, in contrast, those who continue to present & campaign for a wide & diverse range of science led, evidence based forms of recovery, notably maintenance treatment as well as abstinance, are treated with horror as recividist junky's seeking state funding for fun, in denial of their 'true' state of being,as persistant recividist fun loving crimminals, etc-et-al. Hence denied any legitimacy by party's which have a anything other than user 'friendly' agenda.

There must be no room for 'coercion' in the treatment & long term empowerment of users/patients to manage their chronic medical condition.

With respect as ever,

Alan Joyce