Thursday, 16 October 2008

The power of misinformation

Heard a depressing story this week from a friend who holds a senior position in a treatment agency. They told me of a local commissioner who was telling drugs workers that research showed that residential rehab did not work. Therefore, local commissioners were not going to send people to residential. Also, very worrying was the fact that the drugs workers believed what he was telling them!

No wonder residential centres are struggling to fill their beds with this disgraceful misinformation and attitude. How do such commissioners get to hold such a position? And exert such an influence. It is also very worrying that the drugs workers believed the commissioner. 
The level of knowledge and understanding of many people working in the field does really worry me. If doctors and nurses working in our hospitals had the same level of training as many of our specialist workers, generalist workers - and commissioners in particular - we'd be running scared if we got seriously ill.
I don't like having to say this - there are many good and knowledgeable people working in our field - but one cannot escape reality. It is worrying.
As for the commissioner in question - he needs to be told the truth about good residential rehabs. And tell others the true reality!     


Anonymous said...


I couldn't agree more.
To use just one example from a myriad: NTORS.

I agree that the knowledge, skills and understanding of the practitioner workforce needs to be improved. If this kind of ignorance was displayed by a practitioner it should and could (and actually might) trigger some kind of capability response by their manager. Put it this way, if I was their manager, I'd put them straight - supportively of course - in no uncertain terms.

However, one crucial difference is that there is no real clinical scrutiny of DAAT commissioners by their CDRP masters. Partly because those senior Partnership managers tend to know very little about drug and alcohol treatment issues themselves.

Who watches the watchers?

David Clark said...

Blind leading the blind leading the blind

Anonymous said...


David, I've taken exception at the comments made on this blog before about "commissioners", and I take exception to the inference from this.

Drug treatment commissioners seem to be an easy scapegoat. To a certain extent that's the nature of the job. Being in the middle - between the NTA, local PCT and LA requirements and the treatment services- having to deliver systems that fit all of the varying requirements. It's never going to make you popular.

But there does seem to be a real gap in understanding about what the role of commissioners are, what we do, what levels of expertise we hold and what our qualifications and backgrounds are.

David, you site one example of misinformation and bad practice from a drugs treatment commissioner here. I'm sure others could site other examples. I would not seek to excuse these. Commissioners have very visible roles and mistakes and errors, when they occur, are usually noted by many.

But to assume from this that commissioners as a whole have lower skills, or are "blind" as you put it, is an unnecessery generalisation.

I have 12 years experience working in the drugs field as a drugs worker, manager of services and commissioner (both in this country and overseas). I also have experience of specialist consultant psychiatrists, managers of services, people working for the NTA, probation officers, counsellors and psychotherapists, drugs workers and those in recovery making mistakes and errors. I'm sure you do too. Yet it seems easy to scapegoat those working as commissioners as being responsible for problems in the drugs treatment system.

I'd also like to point out to the person making the anonymous comment above that DAAT commissioners DO have a tremendous amount scrutiny applied to their work. Almost everything I do is scrutinised either by the leads of the services I commission, my service user group or the NTA; and I welcome this scrutiny (actually most of it is quite supportive and I couldn't do my job without it). In fact most of my job is about resolving the expertise that these sources provide with the amount of money I have available and the constraints mentioned above (and geting more money and getting rid of the constraints where I can).

Commissioners do come from different backgrounds (as do drugs workers in other arenas), but it is wrong to see our role in general as different in status, quality or direction to anyone else working in the drugs field.

I know a lot of commissioners and most of them are dedicated, committed, well informed and educated in this field. Of those I have regular contact with, all have over 5 years experience in the substance misuse field specifically and nearly all are qualified in a relevant disciple (nursing, scoial work etc).

The problem seems to me to come from the desire to see commissioners as somehow "special and different" and not included in the continuum of delivering drugs services.

No one's perfect, but we are no different to you!!

Matthew (Commissioning Manager for Swindon)

David Clark said...

Well-spoken Matthew.
Except I am not criticising all commissioners - and you. As I say, 'there are many good and knowledgeable people working in our field.' And many good commissioners. I am sure you are doing a great job.
However, there are also many commissioners who are not doing a good job. As there are people at other levels. There are many horror stories and the overall level of appropriate knowledge in this field (as a mean) is not good. If we put our heads in the sand about this, then that is bad.
The NTA is talking the system up all the time - there are many people who believe that some of us need to speak out about the bad. Service users, families and conscientious workers deserve this.
Most of the time this blog is upbeat and optimistic, but I cannot and will not pretend that all commissioners and workers are like yourself.
The system needs radical improvement - that does NOT mean that everyone has to improve. Many people are doing a great job. Many are not.
Matthew, Keep up the good work and keep reading the blog, please.

Anonymous said...


I tend to agree with the general thrust of Matthew's comments. It seems to me that you have a tendency to decide that certain things/people/groups are on the side of 'good' and others are not. In this respect, the recovery 'movement' has more than a whiff of religiosity about it (and I don't just mean of the NA or AA type). I thought it was ironic, therefore, that your criticism of this particular commissioner was based on your view that they were ignorant of the 'evidence' - one of my biggest beefs with your take on recovery is your seeming reluctance to bulid it on a transparent evidence base. I commented on a previous thread about your 72-slide presentation bordering on the vacuous. Would you like to take up the challenge I set you there?

David Clark said...

Transparent evidence base for recovery?! As a scientist for over 30 years, I look at the evidence base. It's the way I work.
It's there in the literature for recovery, you can get the details of the references off my blog. Or just look at the Bill White page on Faces and Voices site. And look at the views of other leading addiction experts in the States and this country. You can do a full search of the science literature.
As for the challenge, what you want is in my blogs and will be on our new online recovery community. I'm afraid the challenge I am taking on at present is more than enough - sorry! But as I say, it's all out there.
Heh, if everyone agreed with me, there would be something very wrong!!
Thanks for your time.

Anonymous said...

I said 'clinical scrutiny'.

I know you are highly governanced by Uncle Tom Cobbly and All. And that's good.

But I'm afraid that even Strategic and Operational Partnershp colleagues in the PCTs (who would be my best bet for knowing about drug and alcohol treatment) are usually (ok often then) just not knowledgeable in the area of treatment themselves.

And nor are Officers of the NTA necessarily either.

You have worked as a drug worker so wouldd't need such clinical knowledge development in all probability.
But many of your colleagues do.
And they aren't always gracious or honest enough to admit that.

tim1leg said...

THANKS for that well thought out reply Matthew from Swanson, i would like to pose a question to you, taken from your quote "all have over 5 years experience in the substance misuse field specifically and nearly all are qualified in a relevant disciple (nursing, scoial work etc)."
"Can you tell me how a relevant is a nursing or social work degree" to our field? I think we need a radical overhaul of this type of thinking and some serious effort to bring the world of so called "addiction professionals" up to speed. having a nursing or social work degree along with years of experience dose not mean one is qualified. I recently did a piece of research of all the commissioners in Scotland and out of those who replied which was over two thirds none yes that's none had any addiction qualifications and only one had had experience of commissioning services before coming in to post!!
point made.

Anonymous said...


Thanks for your time, too! Although I’m obviously a sceptic about what you’re doing, as I’ve said before I strongly admire and value your passion and commitment in trying to tackle a really important problem – and I’m not at all questioning your good faith. However…

I’m sure you believe that your message is based on scientific evidence and much of it does ostensibly draw on empirical research. But it seems to me that some of your foundational positions are more ideological choices than strictly evidence-based. Let me give you an example. In a number of your background briefings you refer to the idea that ‘addiction is a chronic disorder’. Indeed, you use this as a starting point for critiquing some current approaches to drug treatment. You say that you are not adjudicating on the debates about whether addiction is a disease, illness, disorder etc but just considering its temporal course and the implications for treatment that flow from that. An interesting approach, I think, but you then give as examples of other chronic disorders things like diabetes, asthma and heart disease. They are all very particular types of conditions, of course, which whilst influenced by environmental and other factors are fundamentally connected with malfunctions within the physical body. So implicitly you set addiction in the same category as those conditions. Perhaps that is right but it is a very long way away indeed from being something about which there is a clearcut body of evidence. You choose to see it like that and then build other arguments (many of which do rest on good evidence) from it. That’s fine but that’s what I mean about the ideological basis of (some aspects of) the recovery movement.

Anyway, good to disagree as it always stimulates thinking! I’ll leave you to your work now.

Anonymous said...


Not really 'point made' at all. The idea that we need 'addiction' specialists is one of the most damaging beliefs in our current understanding. There is no such thing as 'addiction' - that's just a label we have invented to describe certain types and patterns of human difficulty. What we need are 'helping' services which people can access when they need, without the necessity of attaching labels to themselves first. The creation of an 'addiction' specialism is just another scheme for jobs for the boys (and girls).

Doc Jerry said...

I work as a prescriber in a drug clinic. For that I need a paper qualification. Very little of my qualification helps me in my real work in the clinic which is to help people to look at how they live their lives.
I would not be keen to work in a service that did not have a significant proportion of workers who had personal experience of using the service, as these are the people who best know how to help. I accept that we are better at doing our jobs with training and that paper helps to prove that training but it must always be seen as a means not an end in itself

Anonymous said...


Any particular reason why my comment (copied below) hasn't been posted? Please don't tell me this is a movement that doesn't tolerate dissent or debate! Then I really will think you're an ideologue!


Thanks for your time, too! Although I’m obviously a sceptic about what you’re doing, as I’ve said before I strongly admire and value your passion and commitment in trying to tackle a really important problem – and I’m not at all questioning your good faith. However…

I’m sure you believe that your message is based on scientific evidence and much of it does ostensibly draw on empirical research. But it seems to me that some of your foundational positions are more ideological choices than strictly evidence-based. Let me give you an example. In a number of your background briefings you refer to the idea that ‘addiction is a chronic disorder’. Indeed, you use this as a starting point for critiquing some current approaches to drug treatment. You say that you are not adjudicating on the debates about whether addiction is a disease, illness, disorder etc but just considering its temporal course and the implications for treatment that flow from that. An interesting approach, I think, but you then give as examples of other chronic disorders things like diabetes, asthma and heart disease. They are all very particular types of conditions, of course, which whilst influenced by environmental and other factors are fundamentally connected with malfunctions within the physical body. So implicitly you set addiction in the same category as those conditions. Perhaps that is right but it is a very long way away indeed from being something about which there is a clearcut body of evidence. You choose to see it like that and then build other arguments (many of which do rest on good evidence) from it. That’s fine but that’s what I mean about the ideological basis of (some aspects of) the recovery movement.

Anyway, good to disagree as it always stimulates thinking! I’ll leave you to your work now.

Anonymous said...

As a person with experience both in nursing and working with drug addicted individuals as well as being a recovering addict myself, I have indeed seen people get better with good, high quality (i.e., evidence based, not religion based) abstinence treatment. I have also seen people improve and have much better lives through medication assisted treatment.

However, recovery from certain addictions--particularly long term opiate addictions--is difficult. In my experience, more people than not in this group do require medication assisted treatment to begin to improve. Anyone in the field can tell you they have seen instanced of even the hardest core addicts making a full recovery without it--but that is NOT the norm. The fact is that recovery statistics for that group are NOT good--the success rates for abstinence based treatment for long term opiate addicts are abysmal.

In the USA--where abstinence based treatment is the norm, and where 97% of rehabs use the 12 step model, the success rate, even at the best places, is usually around 30%, and for most places it hovers at around 10-15%. My feeling is that this has to do with changes in the brain chemistry that take place in many individuals who abuse opiates long term (not all), and which may, for some, be permanent in nature. For these folks, no amount of "talk therapy" or job training is going to solve the problem. I think more comprehensive services are needed--not JUST MMT/Buprenorphine, and not JUST lifeskills training (if needed) and resources, but somewhere that patients can access BOTH modalities if needed, and just one or just the other if both are NOT needed. I think this would help to bolster success rates for both modalities if treatment.

David Clark said...

Anonymous (2 above)
Sorry must have missed your posting - don't know how. I put everything up, unless it is one line advertising!
I write more on acute and chronic care models in forthcoming web community site.
It's good to disagree!! And hasn't this particular blog fired up some discussion!
Only trouble is that I'm deep in a large pile of admin and the phone is ringing a lot, and I need to talk to a funding reviewer.
Thanks for your comments.

Anonymous said...

This debate seems to have hit a few raw nerves.

Excellent work!!

tim1leg said...

No such thing as addiction! LMAO, I love philosophy and semantics also. What a brilliant debate, keep up the good work prof.

David Clark said...

No such thing as addiction?

Would you agree that there are serious substance use problems that may need specialist knowledge in some cases to help someone overcome their continued problematic use? Or can anyone be a member of the 'helping service'?

Anonymous said...

I would have to say from my view which is from an ex users point of view that it is extremely necessary to have the right'skill sets' when dealing with vulnerable people. I may be wrong but from my own experience there seems to be too much generalisation in the addiction/recovery field.In my industry you are trained for a specific job,each and every person is trained in the overall view than separatley trained in a specific area so when combined you effectively cover all the bases,i dont see this type of structure in this field and its quite scary considering the damage that could and probably is happening as we speek.

Anonymous said...

No, I wouldn't agree actually, David. Some people certainly have severe problems and difficulties but what sort of 'specialist' help do they actually need? You ask whether anyone could be a member of a 'helping service'. Yes, absolutely! Any human being who can empathise and show compassion will do. Creating 'professions' and 'expertise' of this kind is a way of denying our fundamental human capacity to help and support our brothers and sisters in pain. Nothing special required for that, other than a big heart and a capacious shoulder.

By saying 'addiction' is just a label, I mean literally that it was invented by human thought. Which of course it was - about 230 or so years ago. Which is not to deny the reality of human difficulties and pain but simply to say that calling it 'addiction' is an active process of labelling. This isn't just philosophical navel-gazing either; it has profound practical consequences. Why is that those like yourselves in the recovery movement use the word 'addiction', whilst the government tends to say 'problem drug use'. Think about the types of solutions or responses that accompany those different labels.

Maybe I'm talking rubbish, though. Interesting rubbish, I hope.

Anonymous said...


Remember, sarcasm is the lowest form of wit! Seriously, I wasn't meaning to be insulting, just trying to provoke some different thinking. I appreciate it's a touchy subject to question 'expertise' but surely healthy to do so? You may well be right, and me wrong, but hopefully something comes out of thinking about things we normally take for granted as self-evidently 'true'.

tim1leg said...

Was it Oscar wild who coined the phrase (but being sarcastic of course when he did say it) Sarcasm is the lowest form of wit, but the highest form of intelligence").

I'm sorry if i offended you of course but to suggest there is no such thing as addiction is ludicrous, i understand your point about language, labels and the danger of this, we are in agreement of course on this matter.

Some days its hard to be diplomatic when all to often people in our field seem insistent on mudding the waters and pitching against each other, another reason why its so important that there is a comprehensive understanding of what works in addiction "treatment" as the other anon commenter states there seems to be too much generalisation in the addiction/recovery field. That somehow you can be trained in another discipline and just enter the field because you just can is no longer acceptable.

As anon 2 says In his/her industry they are trained for a specific job,each and every person is trained in the overall view than separately trained in a specific area so when combined you effectively cover all the bases,This type of structure in our field is sadly lacking and again in agreement with the last commenter not only is it its quite scary considering the damage that could and probably is happening as we speak it is downright disgusting and unacceptable and a radical overhaul of the whole field is now well overdue as people continue to die and suffer at the hands of the ignorant.

Anonymous said...


No, I didn't take offence. Nothing wrong with a bit of debate.

I tried to explain what I meant about labelling on another comment which seems to have disappeared in to the ether. I'll try again. It is definitely not just a matter of philosophical navel-gazing. The labels we place on things, people and behaviour profoundly shape the way in which we respond to them. It is no co-incidence, in my view, that the recovery movement uses the label 'addiction' because that goes hand in hand with certain kinds of responses. Have you noticed though that the government tends to use the term 'problem drug use'. Again, no co-incidence. That label goes along with a particular way of 'imagining' the problem which in turn is bound up with a certain focus in the ways of managing it.

Anyway, that's enough thinking for Friday night!

Anonymous said...

Wow, I have just read I am not an addict, was that the commissioner tapping away? Sadly in this huge complexed world of addiction there is far to much in lacking of knowledge and understanding, from all levels in the field, In reality all Counties and the majority of DAT teams have their own agenda which is flawed and serves no purpose to the country as a whole, as for the unbielievable statement by the Commissioner! I would love the opportunity to show the individual that the pros to re hab far out ways the cons to treatment, as for comments of from annoymous that there is no such thing as addiction! "What are you on this site for i put to you?!" Totally behind you David, yet the best part is slowly yet surely the services will improve for the users, familes and professionals.

David Clark said...

Hi guys,
Trying to find one lost in ether. Since I moved to using google mail, I sometimes 'lose' emails', they caught up in a thread and you can miss them. I'll try and find.
Good to see some debate.

David Clark said...

Found it, I should keep checking main blog comments section. I aqree there is always difficulty with labelling. Might have to continue this other day though. I'm multitasking at mo, watching movie (not a good one), reading novel and looking at comments periodically. Bloody man, I guess.
Good debate though, I better provoke some more on other days.

Anonymous said...

Thanks,im glad you agree with me on the point,that there seems to be no 'structure'!!.
It is a very scary scene when you think it is basically a free for all.

What i cant seem to get me head around is why there isnt a for want of a better phrase a'project cycle'which could easily include the majority of variables, as in company formations,structures,training etc the list goes on ,in place or if it is why it isnt being'enforced' is beyond belief.

surely the governing body whomever that is must be able to exert some pressure and narrow down the guidelines to the proposed amount of time needed for people to be allowed to enter the industry,especially the ones who will have direct one to one relations with the user/s.

My field is governed by ofcom/then secondly by the m.o.d and the lack of control/organisation/and training would simply not be accepted.

Ok people could argue the point that it comes down to a lack of funding by the government and i would agree that unfortunately you cant do shit without money but surely if companies(profit/non-profit) could form some sort of alliance and strike some deals with the training bodies as in costs for courses etc????.

just an i would be happy to work on!!!.


David Clark said...
This comment has been removed by the author.
tim1leg said...

anon are you refering to some sort of conspiracy? with the goverment or trying to teach me something, please dont try the subtle appoach, im an addict i need hard facts and the subtely of a large brick when learning!!!

Anonymous said...

I've been out for the evening - lovely time with friends - and just returned. I realise my statement that addiction does not exist was a bit provocative. I reiterate - the pain, problems, difficulties some human beings face exist. The twin question we should ask though is: a) what should we call these difficulties and b) how should we respond to them. I am suggesting that the answers to a) and b) tend to be closely related. Answering 'addiction' to a) leads to a certain set of answers to b). Answering 'problem drug use' to a) leads to a different set of answers to b). In that sense, 'addiction' does not exist as an objective condition, it is a label we attach to a state of being (which does of course exist).

Anonymous said...

most of the people i have worked with in harm reduction do not think rehab is the answer. given that the government agenda is harm reduction and alot of the people working in the harm reduction side of the field are chronically co-dependent it is no surprise to me that there is a sub concious agenda to keep people sick and of rehab and abstinence arouses such extreme emotions in these people, almost could be described as violent and raging, this suggests to me that there are a lot of unresolved issues driving all this.

David Clark said...

yes, people are feeling threatened and don't want change - to the detriment of the people they are paid to help. Actually, they can train to do their job differently - i.e. help people find recovery. If they were caring people that is what they should do once their job spec changed. The ones that don't want to train, should they be in the business?

Anonymous said...

Should they still be in the business??
Absolutely not! I have seen first hand the lack of enthusiasm and drive some(and i say some) people in this field have and they dont realise the knock on effect it has on the people they are supposedly trying to help.

"If the person doesnt care about me and isnt doing everything they can to help me,then why should i care about myself?"

When people go for help,they do so because they are at there end,the courage that it takes for he/she to crawl out from the dark and finally into the light only to be met by a half baked smile and a serious lack of enthusiasm is dangerously unacceptable.

chris g

Anonymous said...

"The Power of Misinformation!"
This I seriuosly believe has been one of the most interesting subjects put out so far David, a good response from all, I find it interesting how defensive individuals become over their roles and how passionate others are with what we believe in! One thing for sure the system is flawed and without change there is no progress and with out progress there is no future. I would really be concerned if anyone struggled with that statement. Well done David you have opened the door to allowing individuals to start thinking about "Addiction!" Look forward to your new website up and running.

Anonymous said...

It seems I come to this debate late. What a lot of responses. Here is my take on some of the above issues.

The evidence base for recovery (drug free) is there. Large treatment studies in the UK (NTORS & DORIS) support this, as do the Australian Study (ATOS) and ROSIE, the Irish study. (Why do we go for female names in the Celtic countries?). There are plenty of US studies. So, recovery happens. It is self-evident that it is less likely to happen in services which don't believe in it and have low expectations of clients. The evidence base is much biased in favour of prescribing interventions as these have been studied comprehensively at the expense of psychosocial interventions which are far harder and more time consuming to study.

Addiction as a discreet entity? Well as human beings we create taxonomies. It's what we do, we look for themes and commonalities and we categorise things accordingly. Addiction certainly fits the bill. It's been categorised as a 'disorder' for many years and fits the bill as a chronic illness according to how medics classify illness. The Prof is not the first person to compare addiction to other chronic conditions. A paper in the Journal of the American Medical Association in 2001 compared it logically to Asthma and Diabetes, studying relapses between the conditions. It makes a lot of sense.

The advantage to this approach of treating it as a discreet entity is that we can apply discreet management approaches to it. We could see it as a symptom of wider societal problems like poverty and inequality, but this in my opinion is much less likely to help individuals who are suffering. Whatever else addiction is, those who have it are truly suffering, as are their families. Addiction is best seen as a discreet problem; that's in the best interest of addicts.

In terms of the knowledge or lack of it in the field; there are examples of good practice and bad practice everywhere. At this point in time though, if you are a service user (0piates) whose goal is a drug-free recovery, the odds are generally stacked against you. You are much more likely to come across practitioners who will encourage you to go onto a long term methadone script than those well versed in the evidence base for recovery. Postings above questioning the evidence base and rather ignorantly labelling NA/AA as 'religious' show that we have a long way to go in helping our colleagues get a grip of the facts.

I am both a recovering addict and a practitioner. I am highly trained with many years of studying and a string of qualifications to display. My experience of recovery helps, but I don't believe it is an essential qualification to work in the field. I think we need a workforce who knows what they are doing, but I believe that as well as that it is just as important to be able to listen to what our clients want and, if it is healthy, help them get there. Most clients (according to surveys and studies) want to become drug free. The fact is that people can recover (I've met hundreds of those who have in my area alone). We have a system that in many places pays only lip service to this goal. That needs to change. The question is how?

As a start, lets get familiar with what works, change our attitude to one of hope and aspiration, raising the bar for clients, train the workforce and those of us in recovery need to be visible and voluble in our communities.

That's my two cents worth.

David Clark said...

What an excellent posting, not just because I agree with what you say. You've put it so well.
We should be aspiring to what you summarise in your last para. I hope that our new website we will be launching soon (let me know if you want to take an early visit) will facilitate this process.
Thank you for your time and clear and insightful thoughts.

Anonymous said...


The twelve steps copied and pasted off the NA website:

"1. We admitted that we were powerless over our addiction, that our lives had become unmanageable.

2. We came to believe that a Power greater than ourselves could restore us to sanity.

3. We made a decision to turn our will and our lives over to the care of God as we understood Him.

4. We made a searching and fearless moral inventory of ourselves.

5. We admitted to God, to ourselves, and to another human being the exact nature of our wrongs.

6. We were entirely ready to have God remove all these defects of character.

7. We humbly asked Him to remove our shortcomings.

8. We made a list of all persons we had harmed, and became willing to make amends to them all.

9. We made direct amends to such people wherever possible, except when to do so would injure them or others.

10. We continued to take personal inventory, and when we were wrong promptly admitted it.

11. We sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.

12. Having had a spiritual awakening as a result of these steps, we tried to carry this message to addicts, and to practice these principles in all our affairs."

See anything religious there?

Anonymous said...

Good point, anonymous. It is at best 'ignorant' and at worst 'dishonest' for Peapod to say AA/NA are not religious.

Anonymous said...

Every single court in the USA who have had the issue brought before them have judged that the 12 step program IS essentially religious in nature and asks that the adherents select a higher power--one that has the ability to hear their prayers and heal them from addiction in a miraculous way, as "no human power" can do so--and that they pary to that power. Any cursory reading of the AA Big Book shows clearly that it is steeped in Judeo-Christian religion--the references to "God" are numerous, intellectual questioning is discouraged, and even the chapter "We Agnostics" is simply a tale of how to move from agnosticism to belief. Adherents are asked to join hands at the end of many AA meetings and recite The Lord's Prayer--a specific, Christian prayer.

No other disease, mental or physical, is treated in such a manner. People with other chronic, long term ailments are not simply told to "surrender" and "pray for relief" and make a list of their sins to share with God and another person and so on. We would be appalled if a schizophrenic, a diabetic, or someone with bipolar disorder were treated thusly. But addiction treatment seems to be the exception, paying lip service to it being a "disease" but then treating it as though it were a moral or spiritual failing, tied up in egotism or "character defects" and curable through a "daily reprieve" if the afflicted remembers to pray, examine their soul, give to others, etc.

Anonymous said...

Thanks for the positive feedback David.

If I was of the despairing type, I'd despair. You spend a bit of time laying out some sensible arguments around the themes under discussion and you get folk picking up on one line like its the crux of the thing!

I suspect it would be a waste of time and energy setting out the stall with the spirituality versus religion debate, so I won't do it here. It's enough to point out that many in AA and NA are agnostic or even athiest. It ain't a religion. On the other hand we have some nice UK research showing that prejudice toward the 12-step groups from professionals working in the field is alive and well.

Good to see it got the 12 steps prominently published on a well read blog! Every cloud...

tim1leg said...

having attended na and aa meetings for almost 12 years both all over the UK and most of the western world now i can asure you, i have never once heard the lords prayer, im sorry but one again ignorance breeds contempt "There is a principle which is a bar against all information, which is proof against all arguments and which cannot fail to keep a man in everlasting ignorance - that principle is contempt prior to investigation."

Anonymous said...

Impassioned thread.

As far as spiritual approaches to disease go, it would be a poor doctor who did not look after the spiritual needs of the patient. We are taught this in medical school. When looking after patients' spirits (the essence of spirituality), we have an eye to the dismay, despair and confusion disease brings. We are thinking about issues including sadness, impaired connectivity, damaged relationships, and uncertainty over meaning and purpose, all of which can be challenging. Let's remember that addiction kills thousands of people each year in the UK; for many it can be a terminal condition. To state that we don't apply spiritual principles to general disease management is not correct. Not that we don't have things to learn. Some of the principles of eastern medicine are being adopted into our more hard science approach, to the great advantage of patients. Spirituality and religion are two different things.

That's not to say that a spiritual approach is the only one we take. We do the other things that work too. It's 'both..and' and not 'either..or'!

Let's not forget also that 12-step approaches are not a minority fad. The National Guidelines (Orange Book); NICE Guidelines on Psychosocial Interventions and NICE Opiate Detoxification guidelines all recommend referral to self help groups as an intervention with clients who want to become drug free.

They state "Staff should routinely provide people who misuse drugs with information about self-help groups. These groups should normally be based on 12-step principles; for example, Narcotics Anonymous and Cocaine Anonymous".

The reason? The evidence says that they work to help people achieve their goals. Isn't that what it's all about?

Jason Schwartz said...

"In the USA--where abstinence based treatment is the norm, and where 97% of rehabs use the 12 step model,"

As a practitioner in the U.S., I can tell you that this 97% number inaccurate. In my area and in many other areas of the U.S., the only treatments that are available on demand are once a week outpatient group counseling or methadone.

A big problem in U.S. has nothing to do with the model. It's that most people can't access treatment of an adequate intensity and duration. People end up doomed to fail because they are homeless and living under a bridge and the system's response is to offer once a week outpatient. No one should point to the U.S. treatment system as a model or test case.

Anonymous said...

Please show me the stats that say inpatient treatment has a high rate of effectiveness for long term opiate addicts--because this is, after all, who we are talking about here, in arguing about methadone vs. abstinence based treatment. I have been to many "high quality" inpatient centers and have NOT found recovery there, despite my best efforts and theirs. And it isn't just me.

Sure, people recommend 12 step support groups.--because until very recently, there was NOTHING ELSE available in the community, and in many areas this is still true. However, the rate of those who are still attending and are sober/clean in AA, one year after starting, is 5% by their own triennial survey. That's not a good ratio.

Trotting out the "It's spiritual, not religious!" argument is a straw man at best. You say you have never attended a meeting in the UK where the Lord's Prayer is used. You come on down to Texas and let me take you around to the AA meetings here. I assure you every one I have EVER been to--and that's a TON--closes with the Lord's Prayer. In fact, a quick glance at the AA Grapevine magazine shows that this issue has come up time and again as something people object to--yet it continues unabated.

Sure, doctors can take into consideration the spiritual needs of their patients--most may suggest a support group or two, although these groups are general support, not ones with a creed, steps to follow, etc. Many may benefit from such groups--and some may benefit from 12 step if they are of a like mindset. But it should not be all that is available.

For example, NA groups in the USA ban methadone patients from participation. They are considered to be "in active addiction"--patients who have not yet "seen the light"--and so must remain ashamedly silent, because to speak or share their struggles might "cloud the message of recovery". Persons doing well in treatment are often sent to these groups by well meaning but poorly trained counselors, and then, wanting to "belong" and not have to sit in silence, they abruptly, with the encouragement of their new friends, stop treatment. More often than not, this ends in disaster--and sometimes death. This is NOT a simple support group experience, with people sharing their different struggles on the path to recovering from their ailment.

tim1leg said...

anon, hey this brings the debate full circle, yes there are crap aa/na meetings and yes there are excellent ones, there are crap mmt services and their are crap ones, there is crap councelling services and there are good ones , comunity and res rehabs ad infinitum, The point is "the power of misinformation" can lead to beliefs that a philosophy of care or standard of service can be completly misrepresented based on an influential figures opinion, rather than hard clear facts.

Anonymous said...


First of all thanks for the web address which i got thru the scottish service-user conference - wow this is a great debate on many levels and in many respects reflects the complexity of living with and recovering from addiction, dependency, substance misuse problems....

I kinda understand the frustration of what can seem like an academic debate around labelling as it can stop us moving forward but there is no doubt that the disease model of addiction not only lends itself to the NA/AA approach, and by the way i recognise it as spiritual not religious and highly successful for some folk but incredibly alienating for others, but can also dramatically shape the type of services out there for service-users.

Whet service-users need is CHOICE in terms of treatment options that are focused on recovery !Will the government back the road to recovery with the plethora of services needed to respond to the needs of the service-users themselves, as identified by the service users themselves. Brenda House RIP Links Project RIP I don't think so. LEAP Project welcome on board, but it isn't for everyone and it certainly ain't for single mums with little family support who don't want their kids goin into foster care. And even if you want to go down the methadone road, it still has its place but needs to be part of the answer not the only alternative, depending on where you live will depend on how quickly you can access a script - i have known clients wait nearly a year with no other 'real' options available - unacceptable !!

And we in the profession, if we can call it that, we have been as 'stuck' as the service-users we are meant to 'help'. The relentless focus on scripts with little other creative responses has led to a stalemate between both worker and user. This and an understanding of the very nature of dependency can only be overcome through training and knowledge and access to good external supervision. The professionalisation of the field, bring it on , it is overdue, there are too many 'stuck' and ill equipped workers out there. Lets stop protecting them , its time to shape up or move on.
Yes i still believe that it is the quality of the relationship between worker and client that can be transforming but 'tea and empathy' are not enough and do not stand alone.
Anyway enough ranting from me, i have the pressing need to think about how service-users can be truly involved in the project i work for and not just some tokenist gesture.

from someone who managed to become 'unstuck' and began to believe again.

tim1leg said...

from someone who managed to become 'unstuck' and began to believe again. Hi anon and welcome to the debates, im so glad you picked up on this site from the presentation at the first service user conference in Scotland, it truly was a fantastic and hopefully ground breaking day. I wholeheartedly agree with everything you say about advocating for choice, the current situation is no longer acceptable and I admire your comments about the workforce. Bring it on and more power to you.


Thank you Prof. At last some truth about residential rebab and the authors of discontent who sabotage these units one way and another. Have you any idea how many residential centres there are in Scotland? And have you any idea how many DAATs actually refer to these centres? The truth about that will fill your blog. Thanks again. Bill. Fife

Anonymous said...

No wonder 'anonymous' hides their identity, with such a vast ignorance about the field of recovery from addiction; it is really scary to think they might even work in this field and impact people's chance of life.
There are already some excellent responses so I will limit myself to a link to empirical research about the dysegulation of the mesolimbic dopamine system confirming that there is such a medical condition as addiction disorder. It is here:

Anonymous said...


I've read this kind of stuff before and still find it woefully unconvincing. I'm astonished, in fact, that people are still peddling this garbage after so many years. If you honestly believe that neuroscience is going to sort out the 'drug problem', then good luck to you. But it isn't, sadly.

David Clark said...

I have finally been tempted to enter the debate again, maybe not just to push us up to 50 comments but also as I have something to say.
I am a former neuroscientist (25 years worth) and so-called 'expert' in brain dopamine systems and the neurobiology of addiction (I received a number of research grants, awards, and published many papers in these areas.
As far as I (and many others) am concerned, neuroscientists have not proved addiction is a disease. They have a theory relating to the dysfunction of brain dopamine systems and their link to addiction - no more than that. Even if there was such an irrevocable connection (which there is not), this does not mean that addiction is a disease.
We must not get carried away by neuroscientists just because they work in the brain. This does not mean they are right!
We must also remember that drawing such links helps them get more research grants (the bread and butter of their existence), particularly in the US where NIDA (major grant funder) scream very loudly that 'addiction is a disease' - sadly this message comes over very much louder than trying to find realistic solutions.
Sorry for being so cynical. But I believe in scientific proof, not heresay, poor science, or jumping too far forward with ones conclusions. I spent far too many years watching the neuroscience addiction business when in its midst.
One point which made me realise the limitations of neuroscience and change fields was:
whilst I could give a spanking good talk about the neurobiological mechanisms underlying addiction (yes, I also played the grant game), I did not feel that I (or other neuroscientists) had helped anyone find recovery from addiction.

Anonymous said...

Not sure I am so unconvinced by the evidence. Much of the stuff that NIDA has done in the States has been replicated elsewhere. Animal disease models of addiction show us that lab rats behave very like human addicts do and of course in general rats are not known for poor parenting, poverty and social exclusion or learned behaviours around addiction.

The genetics of addiction is being unravelled and large scale population studies show a strong genetic component. Kids born to alcoholic parents are several times more likely to develop alcoholism than those not. The risk stays with them even if they are adopted at birth into non-addicted families. No learning how to do it from your parents in these cases.

Brain scanning (fMRI scanning) has transformed our understanding of the circuits involved in addiction and long term changes can be shown consistently in the brains of addicts across a range of substances. Even since you gave up the day job as a neuroscientist Prof (and we're glad that you're doing what you are doing), the evidence continues to pour in. I have an interest in this and monitor the journals and I find it very hard to keep up with progress. So much is happening. Sure much of what we understand is superficial and basic and there are many theories around, but that's the same for lots of conditions we don't understand but call diseases.

As a doc, I think addiction fits the bill very well. We have good evidence for disordered brain physiology (both structural and chemical), and it has to be said that this is way more complex than the mesolimbic dopamine pathway); we have well recognised sypmtoms and signs of addiction (often not acknowledged as such as they are mostly behaviours and we don't usually think of behaviours as symptoms, though there are plenty of precedents for this in other diseases); we have an understanding of the likely course and effects of addiction and like many diseases we cannot cure it, but we can treat it and expect resolution of the symptoms. These components define many other diseases. If it looks like a duck (disease), sounds like a duck and waddles like a duck, why don't we call it a duck?

Actually I don't think calling addiction a disease lets anyone off the hook. We don't say to the diabetic, poor you, sit in the corner with some buns and eat away until you have a stroke and die. We say; it's not great news, you have a disease. Here's the good bit; we know what's wrong with you and we know what you need to do about it if you want to get well. I say to my patients, 'we don't think it's your fault that you're suffering from addiction, but it's entirely your responsibility what you do about it'.

I can't agree David that neuroscientists haven't helped addicts recover. For our patients, we tell them the science, we help them understand (based on current information) just why it can be so challenging to stop using, make healthy choices and why in those early days of recovery life feels so 'greyed out'. Current science does shine a light on this. Recovery can be tied into the science and for many clients helps them to overcome shame and guilt. So give yourself more credit!

I think addiction is a complex disorder with many presentations and variants. I don't like to be reductionist and I agree that we need to be careful in our interpretation of the science. There is a lot of bad science around.

Personally I believe that ONE of the things addiction is, is a disease. It has many predisposing factors and there are multiple models out there (including the moral model), but I find that it's logical (in my mind and in the minds of many others) to call it a disease. Let's not forget that many people die of this condition. It has a significant mortality and for those who don't die a significant morbidity; both compatible with a disease process.

We can argue about the number of angels that can dance on a pinhead until the cows come home (mixing my idioms here), but whatever we believe, most of us agree that recovery is possible for many people. In my team we put an enormous effort into helping people do just that. I suspect that some of the energies we put into disagreeing with each other here could be better directed!

tim1leg said...

blooming heck DR Dave, Thanks for that, well done and hear hear.