Wednesday, 16 August 2017

Are we all alcoholics now, or is none of us?



This post is really a reflection on a recent article by Nick Cohen in Prospect, prompted by an exchange on Twitter between Andrew Brown and James Morris about whether the use of word ‘alcoholic’ is accurate or helpful.

So before I launch into something of a critique, I should say that the article itself is definitely worth reading.  It’s brilliant at identifying how drinkers are so adept at deflecting criticism of their own drinking (though they’re not unique in this – think of how we all seem to think we’re above-average drivers).

But he’s also great at conveying the emotions linked into drinking with a more personal perspective.  I’m going to quote at length here, which I hope isn’t a breach of copyright:


At the end of January 2017, I could not find a good enough reason to start drinking again. I still remembered the allure of alcohol, its promise of comradeship, love and simple pleasure. For me the most romantic lines in English poetry are from Edward Fitzgerald’s Rubaiyat of Omar Khayyam:
“Here with a Loaf of Bread beneath the Bough,
A Flask of Wine, a Book of Verse—and Thou
Beside me singing in the Wilderness—
And Wilderness is Paradise enow.”
But after too many years and too many flasks, neuroticism replaces romance. No one who hasn’t experienced it can appreciate the obsessiveness of the determined drinker. Questions build up as the evening approaches. Where am I going to drink? Who can I hassle into a pub? Can I sneak another one in without anyone noticing?
By the time you wake up in the morning, obsessiveness has metamorphosed into paranoia. What did I do? Why can’t I remember? Who did I offend? How did I get home?
If you find yourself asking these questions too often, the best answer is: “I give up.” How best to give up is, like everything else to do with alcoholism, infuriatingly hard to pin down.

All of that resonates probably a little too much with me.  I feel that ‘allure of alcohol’ and its ‘promise of comradeship’, but equally feel that these are, in reality, pretty illusory.  From a personal perspective I have asked all those questions at various times – though more recently I’ve decided that I don’t mind if anyone notices I’m having another drink; it’s no longer a question of ‘sneaking’ it in.

But from a professional perspective, one point is particularly resonant – perhaps without Cohen realising it.  He suggests that if we’re asking those questions too often we should just ‘give up’.  And I’d respond in the same way: if ‘everything to do with alcoholism [is] infuriatingly hard to pin down’ then I suggest we ‘give up’ using the word too.  It can’t possibly be helping, given that the purpose of a concept like this is to make sense of world – or at least create some useful questions – not simply ‘infuriate’ the interested thinker.

This is particularly odd when Cohen goes on to critique the disease model, emphasising that this is really a problem of behaviour (at which point I should plug the New Directions group and the (even ‘newer’) Addiction Theory Network, as well as this excellent blogpost on the disease model of mental health.

He challenges the idea that ‘alcoholics’ are this special breed, easily identifiable – because we are so bad at pointing the finger at the other easily identifiable groups: “The true alcoholic is always someone else. The old man in the park no one wants to know, the young woman sprawled on the pavement. Anyone and everyone, except you.”

And yet he goes on – just after criticising industry involvement in alcohol policy – to write that “Most drinkers are fine and healthy and good luck to them. Public policy needs to concentrate on helping alcoholics” – a line straight out of the industry playbook.

Of course, as I’ve written many times before, simply because something is said by an industry spokesperson, doesn’t make it untrue.  But as Cohen’s just pointed out, “the line between the heavy drinker and the terminal drunk is as blurred as your vision after a “good” night out.”  And if that’s the case, aren’t we really better talking about ‘heavy drinkers’ in general?  That would catch the attention of the right people without the risk they’ll ignore the message.

Of course the case could be made – as Andrew Brown did – that ‘alcoholism’ is a good way to grab attention for an important issue.  This is more about journalism than technical accuracy.

But again, he’s just told us that ‘alcoholic Calibans always see someone else’s face in the mirror’, so if someone talks to us about ‘alcoholism’ then we won’t be thinking of ourselves.  I just don’t think trying to redefine and re-purpose an ‘infuriating’ and indefinable concept is a good marketing or communications tactic.

The article seems to be trying to have its cake and eat it: we define ‘alcoholic’ too narrowly, seeing them as a special breed when in fact lots of us have problems and don’t acknowledge it; but equally most people drink safely and happily and we just need to focus on that special problematic group of ‘alcoholics’.

I think the biggest problem in this argument is that concept of alcoholism, which takes us down blind alleys of trying to define it in an effective way when, as I suggested at the beginning, we’d be much better off if we just gave it up.

The most important insight in the piece is perhaps about moving forward from problems.  Cohen writes, “The best guess is that drinkers stop when they have the usual prospects of happiness to fight for: a life worth living and the love of others.”

The problem, and therefore the solution, lies in a broader understanding of what makes life worth living – and although there are similarities, we all have our unique challenges and issues with this.  To go back to that lengthy section I quoted at the beginning, that’s why it’s an ‘infuriating’ task to define exactly how best to give up: each person is unique.  ‘Alcoholism’ as a concept, for me, just skims over these differences and challenges and encourages us to think only about the booze.  As Cohen would surely agree, there’s a lot more to life than that.

Friday, 4 August 2017

Public Health and the power to persuade: Are we winning the argument?

I often write on this blog about evidence-based policy, but I want to write this week about how I feel torn in relation to this issue.

I was reminded of the ‘evidence-based’ phrase as I saw responses to the Government’s new drug strategy and the release of the latest drug-related death figures.  Transform, Release, Alex Stevens and others stated that the government was ‘ignoring’ evidence.

But on a quick Google search, I can’t see that Amber Rudd or Sarah Newton particularly used this phrase.  I’m not saying they didn’t use it at all, or that they wouldn’t want to make this claim – Sarah Newton did challenge the idea of decriminalisation on the basis that: ‘When you look at all the other available evidence, we just don't agree.’  I’d just suggest that they weren’t quite using the same ‘evidence based policy’ frame for their arguments.

On the Home Office webpage launching the strategy, the only reference to ‘evidence’ comes from Paul Hayes, which probably says more about the discourses of lobbyists and policy commentators than politicians.  As Alex Stevens’ own research would predict, the politicians were more interested in appearing ‘tough’ on ‘dangerous drugs’, as Sarah Newton put it in that article for DDN.

I should of course make my standard statement that when people cite evidence, it’s usually in relation to one ‘outcome’ of concern – in this case, drug-related deaths.  There is indeed good evidence that things like purity testing, drug consumption rooms, prescribed heroin, retention in treatment etc all reduce drug-related deaths (DRDs).  The problem of course comes when you acknowledge that DRDs aren’t the only outcome policymakers might be interested in (and they’re not the only drug-related outcome we should be interested in).

Regardless of our feelings about them, policymakers have other legitimate concerns: for example they worry that certain initiatives might undermine the fall in young people using substances.  That is, that decriminalisation or drug consumption rooms, or pill testing might send out the ‘wrong message’.  Giving them the benefit of the doubt, this could be genuine concern regarding harm reduction, as much as appearing ‘tough’.

(As an aside, it’s interesting that many of those who campaign on alcohol policy in the name of ‘public health’ would prefer to see fewer people using alcohol on the basis of the population model of alcohol-related harm, whereas those who campaign on policy relating to other drugs under the same banner often see no issue with more people using, and focus entirely on ‘harm’.)

But, more importantly, this isn’t just about harm reduction and drug-related deaths.  It’s also about morality.  You might think it shouldn’t be, but all politics is about morality.  Housing policy, inheritance tax, unemployment benefit – we can use ‘evidence’ in these arguments, and use economic theory to argue that putting a pound in the pocket of someone on £20,000 a year will benefit the economy more than putting it in the pocket of a millionaire, but that can’t be the end of the argument.  There will still be a discussion about whether that person ‘deserves’ that money.  And this is an important and necessary debate – because no matter which side of the political fence you sit, there are times when the ‘evidence’ for some perceived positive effect simply cannot outweigh the moral distaste you feel for a position.  And there’s the broader slippery slope argument: even if you don’t oppose this specific measure, it dilutes a point of principle that makes later distasteful initiatives more likely.

Here, we can see quite quickly how this applies to all parts of the political spectrum.  Peter Hitchens is quite open that his position on ‘drugs’ isn’t simply about the objective ‘harm’ they cause; it’s that taking intoxicants is somehow ‘wrong’.  And for all that left-liberals often like to think they’re wholly swayed by evidence, the ‘evidence’ would suggest otherwise and in fact ‘the Labour Party is a moral crusade or it is nothing’.  Finally, libertarians like Chris Snowdon often make use of the slippery slope argument.  For perfectly legitimate reasons, we don’t simply judge individual initiatives by their specific impacts on one outcome.

And most commentators on drug policy accept this – or at least are resigned to it.

Now here’s where I feel slightly torn.  My view on this blog is typically that we should acknowledge the complexity of policymaking and evaluation, and even then not discount the importance of moral or political positions; policymaking can’t simply be technocracy (even if we wanted it to be).

But then when it comes down to it, this can make me feel uncomfortable.  That is, the whole point of this blog is to encourage careful, nuanced thinking, and question black-and-white thinking, when most of life is more complicated than that.  Unfortunately, a critique of the ‘evidence-based’ position can somehow lead to an equally absolutist position of ‘anything goes’.  That is completely at odds with the aim of ‘thinking to some purpose’, as anything goes requires no thought at all.

What I mean is: even if the root cause of your position is irrational, or personal, you need to be able to articulate and explain it, maybe by saying that a certain policy is just a moral red line for you, or it just feels wrong, and describe why.  That isn’t to devalue the point; just to explain it.

And this this can sometimes be difficult and uncomfortable.  That thinking process shouldn’t simply be about saying ‘I think it so it’s reasonable’; it’s about reflecting on why you react in a particular way, and explaining it to someone else.

But when we acknowledge that, as the New Yorker article I linked to put it, ‘facts don’t change our minds’, this can open a can of worms.

As a response by a communications professional to a recent Guardian article put it: ‘telling people you’re wrong doesn’t work’.  This is generally true (although often not in a professional context, where in my experience we all seem much happier to look at evidence and change our minds), but the complexity is illustrated by the fact that the author – Nicky Hawkins – gives examples of successful campaigns that actually did exactly that: telling people they were wrong.  She explains how drink driving campaigns persuaded people that the issue wasn’t simply about ‘drunk’ drivers as much as the fact that anyone with a certain blood alcohol level will have slower reactions and poorer coordination.  That wasn’t just a way to justify the campaigns; it was the actual aim.  Deaths on the roads aren’t just caused by ‘alcoholics’.

But here’s where the difficulty arises.  The other example given is the justification for the smoking ban, where the villain of the piece became (apparently) second-hand smoke, not smokers themselves.  I don’t want to go into this in too much detail, partly because plenty of readers will know this example better than me.  But suffice to say…
(1) the timing of this campaign made it easier: there were fewer smokers, with rates particularly low amongst affluent/influential groups, so that even if smokers saw this as a personal attack they weren’t a majority or in a great position to make their voices heard.  (Of course the tobacco companies were in a strong position, but the argument wasn’t framed in relation to them, and their credibility amongst the general public was pretty low at this point.)
(2) The apparently desirable effects weren’t just about second-hand smoke; they were about persuading current smokers to give up.

So this wasn’t simply a brilliant campaign; the context is crucial, and there was some selective truth-telling (if that’s a phrase) in the accompanying justification.

There are lots of examples of this in politics in recent years (and actually, forever), so it’s a bit odd for a communications professional to offer this as a great insight.  Two recent classic examples prompted me to start this blog: drug treatment isn’t actually about crime and blood borne viruses, and tuition fees aren’t actually about getting students to pay their own way.  (The latter one is particularly egregious, because the burden to the taxpayer is not reduced, despite the popular narrative.)

I’m not saying the smoking ban was a bad idea, but I think it’s a classic case of not ‘thinking to some purpose’.  If the aim was to reduce passive smoking, then there are all sorts of options other than a ban that would have been workable.

And it’s much easier to ask people not to harm others than it is to suggest they should behave differently to stop harming themselves.  Interestingly, the same applies to the drink driving campaign: the most powerful point is that you could hurt someone else, who is innocent or your ‘vice’.

Most of the key public health debates today, though, are about people’s own decisions.  Perhaps the best way to frame these is, again, in terms of the structure that shapes these decisions: licensing, labelling, regulation, pricing.  But if the communications is designed for the general public, to directly change their decision-making, then unfortunately ideas of ‘passive drinking’ and the like have proved much less convincing; the argument is still about stopping people doing harm to themselves.

I know I’d be mistaken in hoping for some kind of Habermasian perfect communication and debate, and that kind of unrealistic aspiration is exactly what I try to critique on this blog.  My issue, as usual, is where to draw the line when you’re faced with a sea of grey, rather two clear camps of ‘good’ and ‘bad’.

The reason this has particularly resonated with me in the past couple of weeks isn’t just the fact that these three releases/articles have occurred; it’s also that I heard in my professional capacity that, pre-figuring the words of the breastfeeding article, public health professionals need to change the way they communicate with the public.  This sounds reasonable, and personally I’m not a fan of the preaching or evangelical approach – not because of its manner, but simply because I don’t share its view of the ‘good life’.  My objection isn’t the means, it’s the ends (although I don’t think you can separate them neatly).

I’m now going to draw on two people more experienced and intelligent than me.

I remember discussing with one academic a time that doubt crept into their mind about public health and the power to persuade.  If public health, in its attempts to compete with, say, the tobacco industry in trying to shape people’s beliefs and behaviour, adopts their principle of ‘persuade at almost any cost’, what makes it better than them?  That is, we have to be very careful about defining what makes ‘social’ marketing ‘good’, and ordinary marketing ‘evil’, as Gerard Hastings might put it.

This was a personal epiphany, but the general point isn’t a new insight, and it has some broader – moral – implications, to bring the discussion back to where it started: that policymaking can’t just be about technocracy.

And so to reference the other wiser head: James Nicholls (amongst others) has previously drawn attention to the role of alcohol in liberal political thought.  So let’s lookmat the nineteenth-century debate between John Stuart Mill and TH Green.  (And apologies if I oversimplify or misrepresent.  Go read James’ work if you want proper political theory.)  While Green felt it was illiberal to allow people to ‘enslave’ themselves to alcohol, and therefore recommended banning the substance, Mill rejected this argument – despite having used it to justify the abolition of slavery.  Mill suggested instead that if we’re really concerned with people’s moral behaviour, we shouldn’t use prohibition to shape it.  Someone who is only prevented from doing something immoral by the lack of opportunity isn’t showing moral character; they’re in fact behaving a lot like they’re a slave to the system.  The real show of moral character comes in making the ‘right’ choices.

And this position is further strengthened by Mill’s ‘harm principle’ that state intervention is justified when people’s actions impinge on others.  Of course in reality this is impossible to identify: no man is an island.  But the principle stands, even if the reality is more complicated.  (I can expand on this, but I think that’ll do for the moment.  Let’s just say if I do something, it potentially increases the likelihood that you will, so my decision isn’t entirely free of effects on others.)

So taking those two academic insights together, I feel uncomfortable if public health is somehow looking to change its approach.

Presenting facts is reasonable: if you drink too much you’re more likely to die earlier.  And actually evangelising is reasonable too: I believe that a longer life, full of physical activity and clean living is more rewarding and morally more valuable than other ways of living.  (I actually don’t.)

But mixing the two together, and persuading people to do something for one reason (‘you’ll love it’, ‘it’ll make you happier’) when your real reason is something else (‘the evidence suggests people will live longer and costs to the NHS will be reduced’) is distasteful to me.

And as I outlined right at the beginning, distaste can be a reasonable argument for rejecting a position, if explained.  So here’s my explanation: my distaste is that getting people to do the ‘right’ thing for the ‘wrong’ reasons is patronising and, at the risk of sounding like Chris Snowdon, a ‘slippery slope’.  If the current approach of public health professionals, with either evangelism or emphasis on ‘the evidence’ is considered patronising, wouldn’t this be even worse?


Of course you could ask: if there are two likely effects of an intervention why wouldn’t you emphasise the more powerful one?  And there might be some moments when the evidence and the emotion neatly intersect and provide powerful arguments.  But I suggest we should judge any such intervention by a crucial question: have you actually won the argument?  If you don’t care about that question, I’m not sure we’re on the same side in any debate.

Tuesday, 25 July 2017

Writing a drug strategy is just like choosing a suit

Over the past week or so, I’ve obviously read a lot about the new drug strategy.  Mostly short comments on Twitter, sometimes pulled into threads.  I’d also recommend reading the evaluation of the previous strategy and, if you’re interested in treatment specifically, the new Orange Book guidelines.  Or at the very least, Andrew Brown’s excellent summaries of them here and here!

(If you want a summary of my response, see this thread.  This blog post will try to make some bigger, broader points about policymaking and politics.)


My abiding impression is of a lot of sensible words, but without power or resources to back them up, I can’t see how anything will change.  This is a strategy that, in an environment of at least 20% cuts – and almost certainly more once the ringfence for public health comes off in the next couple of years – promises that quality and outcomes will improve, and a wider range of people will receive more tailored treatment.  I just can’t believe that.
I don’t want this post to simply be a rant against austerity, or an unreflective claim that any reduction in funding must equal a reduction in quality.  In Dorset we’ve been open in acknowledging that we can deliver treatment more efficiently and effectively than we have in the past by taking on the vision of ‘phased’ and ‘layered’ treatment from the Strang Report, and there is some truth in the idea that tightening resources can focus the mind and force people to work ‘better together’.

But that kind of approach depends on making some hard choices.

There is a certain efficiency in a Fordist approach to public services where everyone gets the same thing.  There will be some sweet spot of efficiency between that Fordist ‘any colour so long as it’s black’ approach and fully individualised, tailored services.  As usual, I’m going to suggest that compromise is a good solution.  Think of suits (as I often do).  For most people, it’s not ‘efficient’ to buy an expensive tailor made suit.  But that doesn’t mean we all have to wear the same suit.  There’s a nice sweet spot of buying ‘off the peg’, but being able to choose a range of sizes and styles from a range of providers.

But what’s the choice between Marks and Spencer and Moss Bros got to do with drug treatment?

Well, the point is that there should be some ‘tailoring’ of treatment, but within certain limits.  And certain styles or sizes are cheaper and more easily available than others.  So I might buy a tailored or more expensive suit for a special wedding, but have a few cheaper ones for work.  I would find it laughable if someone suggested that I should buy enough tailored suits to see me through the working week – unless of course they were about to massively increase my pay, or force me to reduce my mortgage, or how much I spend on food and drink.  The point is, I’d need to make some trade-offs.

Now, in this increasingly tortuous analogy, we can think of the commissioner as the suit-buyer, and treatment as the set of suits.  And this is when I haven’t even mentioned the ‘chinos’ of brief interventions (not to everyone’s taste, and not the full outfit, but cheaper than a suit) or the t-shirts of needle exchange (a good, cheap, reliable, low-level intervention).  Some interventions or moments are the ‘wedding’ occasion: it’s worth putting in that extra effort because of the reward of getting it right.  For others, it makes more sense just to have a decent, long-lasting M&S work suit.

The point is: someone needs to make this choice, and we can’t have a wedding-standard suit for every day of the week.

But the strategy seems to pretend that we can.  It describes having ‘a targeted approach for high priority groups’ (p.10), and then proceeds to list just about everyone who might have a ‘substance use disorder’ (or whatever you want to call it) or is at risk of one:
  • Vulnerable young people
  • Those not in education, employment or training
  • Offenders
  • Families
  • Intimate partner violence or abuse
  • Sex workers
  • Homeless
  • Veterans
  • Older cohort
  • Users of new psychoactive substances
  • Participants in chemsex
  • Users of image and performance enhancing drugs
  • Those who misuse or are dependent on medicines (whether prescribed or over the counter)

I would struggle to think of someone who doesn’t tick one of these boxes.  I suppose it would be a single person in work, living on their own, who is neither young nor old, not using NPS, IPEDs, participating in chemsex or misusing any medicines, not engaged in crime or sex work, and has never been in the armed forces, and still has stable accommodation.

There could be a 35 year-old heroin user who fits the bill, but I think they’d be doing well to have stable accommodation on their own, be in employment, and not engaged in any form of criminal activity.  And in fact, I might even go so far as to suggest that, if they ticked all those boxes, by definition they don’t have a (severe) substance use disorder, because while they might have some form of dependence, it’s harder to see how their life is being affected by their use.

Maybe I’m being facetious, but I want to make a genuine broader point.  Policy discourses are filled with people talking about ‘targeted’ provision, or identifying ‘priority’ groups.  But a ‘target’ by definition means there’s some other place you don’t want to hit.  A priority can only be defined if there’s something you’re not prioritising.  Both locally and nationally, I fear that politicians and policymakers are reluctant to admit this trade-off and make the hard decisions.  But that should be what real leadership is about.

The sad thing is that this isn’t new.  Because I’m a slightly odd person, I’ve recently been spending my free time reading about the ‘new public management’.  The best book on this I’ve found is The Managerial State by John Clarke and Janet Newman.  This was published in 1997, and includes the following two sections that seem sadly resonant today:

Those working in public services are having to manage not just budgets and people in the pursuit of greater efficiency, but the tensions and dilemmas of rapid and unpredictable change.  The results are frequently high levels of stress and overload which tend to spill over into ‘personal’ life.  At the same time, however, these managers have engaged with the challenge of building more responsive, flexible and user-oriented public services. (p.x)

Dissent from the discourse is difficult to articulate – in the sense of having few pertinent vocabularies through which it can be spoken.  This does not mean it is absent.  On the contrary, it is clear that there continues to be a variety of sources and forms of dissent, ranging from defensive conservatism to marginalised radicalism both within and beyond the state.  But the scope of the discourse of change has meant that much of this exists in the form of passive dissent.  Familiar examples are the patterns of scepticism or cynicism that are a recurrent response to the inspirational language of organisational transformation.  This treats the discourse of change as ‘empty rhetoric’ – a dazzling imagery that conceals a grim reality of declining services, shrinking resources, and gung-ho managers following the latest big idea while the front line struggles on. (p.54)

I’m afraid that, in light of this strategy, the last sentence of this paragraph rings even more true to me.  I’m not optimistic we’ll see any change in favour of more realistic discussions and debates any