A few weeks ago I was at the annual conference of the
wonderful New Directions in the Study of Alcohol
Group (NDSAG), which also hosted the launch of the Addiction Theory Network,
including such luminaries of the field as Nick
Heather, Marc Lewis
and David
Best, amongst others. I could
highlight any number of speakers from the conference, from John Hill’s personal reflections
on a career in the field to Marcantonio
Spada’s discussion of metacognitive beliefs, or Lucy Rocca’s discussion of
her own recovery story and the establishment of Soberistas, through to Reinout
Weirs’ discussion of free will.
Throughout, I felt there was one core theme. Whether we were talking about the experiences
of commissioners, providers or service users, there was a real emphasis on
people’s individuality. We shouldn’t be
searching for one single definition of problematic drinking, or one solution,
or one structure for implementing this.
We need to, as other people put it, treat people as people with people.
Despite these continuities, this theme was expressed in a
range of ways. And so I
argued that we sometimes focus too much on where or how to cut the
commissioning ‘cake’ – should treatment be housed in the NHS, or local
authorities, for example – when the best and most efficient thing to do is to
accept the situation and focus on getting the right people in the right jobs to
deliver the most effective and efficient service possible. But this also led to discussions of what
treatment itself should look like.
Lucy Rocca noted that lots of the people who engage with her
site – notably middle-class women – wouldn’t feel comfortable or confident
accessing ‘mainstream’ community treatment services.
Rowdy Yates
noted that we should look at the particular assets an individual has in terms
of ‘recovery capital’, and make sure that we’re topping them up at an
appropriate rate – if we deal only with the ‘drug’ issue someone has, reducing
cravings for example, but don’t deal with their social relationships, then
we’ll be reducing their chances of recovery.
Marcantonio Spada emphasised that in applying a particular
treatment (CBT), we have to be aware that people’s beliefs about their brain,
body or ‘thinking’ will influence its effectiveness. If we think ‘I need to control my thoughts at
all times’, then this presents particular challenges. We can’t simply apply a single programme and
imagine it will work for everyone.
Similarly, Phil
Harris noted the importance of the life course to argue that we need to ask
of any approach to treatment not simply ‘does treatment work’, or even ‘does
treatment work for this person’, but ‘at what moment’ does it work.
Sarah
Wadd, with particular reference to older people, noted that there are many
reasons for drinking, and therefore we shouldn’t imagine there could or should
be one approach to engaging people or changing their behaviour.
This point was taken up by Doug Cameron in the Q&A after
the session launching the Addiction Theory Network. If, as the panellists had suggested, the
‘brain disease’ model of addiction is so flawed, why hold onto the idea of
addiction at all? The
DSM definition of what it calls a substance use disorder lists a whole range
of criteria for diagnosis – some or all of which may be present, suggesting
something more akin to a spectrum. And
indeed that is the public health model of approaching substance (mis)use. And of course a consequence of identifying a
whole spectrum of issues is that a strong case can be made for making a
available a whole spectrum of interventions.
But of course in reality there hasn’t been a spectrum of
treatments for substance misuse – and some would
argue that under the NTA, there was very little on offer for alcohol users at
all, let alone tailored variety. So
in some senses it’s fair that this issue of variety and nuance should be raised. However, thinking, as I often do, in a rather
self-centred way, it felt a bit harsh on commissioners to be hearing these
calls for accessible, tailored treatment at a time when funding for this
service area is being cut by at
least 20% in line with the public health budget – and that’s if addiction
services have made their case strongly enough to local politicians ahead of the
myriad of other things that could be badged ‘public health’ interventions.
I started to wonder what we’re hearing (and making) these
calls now. It would make sense if the
cracks in the system were starting to show because sufficient money was no
longer coming in to cover them up. That
is, as services are stretched, some people end up getting a less good deal than
others.
Some would argue this is happening in relation to drug
treatment, particularly with the recovery agenda, meaning that those with more
complex needs, or who are less likely to make quick progress, are selected out
of a system that is primarily interested in achieving ‘successful
completion’. Personally, I think there’s
no need for this to happen, and I think it’s a mischaracterisation of most
treatment systems. But more importantly
in the context of New Directions, this just doesn’t apply to alcohol. As those who complain about alcohol treatment
being the ‘poor relation’ to drug treatment make clear, alcohol treatment
hasn’t had that level of funding to paper over any cracks.
In one or two instances, it’s possible that this increased
focus genuinely represents a change in need.
Perhaps
middle class women are drinking more, in greater numbers, than in previous
generations, and that’s why Soberistas has found plenty of users. And similarly, people
in and approaching retirement today are drinking more than their counterparts
20 or 30 years ago, and so again it’s only fair that we consider whether
current services match tis potential emerging need for treatment.
At the same time, there’s something about the timing of the
investment and the research and policy positions now being developed and
outlined. We had a period of
well-funded, clearly-defined, centrally-controlled treatment. Now the NTA is no more, and there is more
local autonomy, there is the opportunity to consider whether things could be
done better – with a real prospect of actually implementing alternative
approaches. And this opportunity is
further strengthened by the fact that there’s over a decade of data and
experience of what that ‘monolithic’ approach delivered.
I’d suggest this idea of focusing on people as individuals
is part of something bigger. New
Directions has always prided itself on ‘providing a safe environment for
original thinkers and speakers since 1976’.
And this means an emphasis on careful thinking, as opposed to comforting
but superficial beliefs. Wulf
Livingston highlighted issues around language in the field. We talk about substance misuse, but not all
substances are drugs, and of course as
I’ve written before, the word ‘drugs’ is pretty meaningless in any
case. And what about that word
‘misuse’? Is it misuse to use substances
that are narcotic, psychoactive or in some way affect one’s brain, for
precisely that reason: to alter one’s mental state?
So if you’re interested in looking at the detail and nuance
that lies behind established orthodoxy, I’d recommend joining the New
Directions group and coming along to the next event or conference. The principle was wrapped up in Nick
Heather’s point about the next stages of evaluation of apps and online
interventions: let’s conduct research that’s designed not simply to find out if
they ‘work’, but rather to identify the mechanisms behind any effect – why
they work. There’s plans for an event
for early-career researchers later this year, and then next year’s conference
is a one-day event in Sheffield.
But to finish by returning to my self-centred perspective, I
want to ask again about that focus on individualised treatment in today’s
environment. I am still slightly worried
by this focus: that it may become a stick to beat the sector with. That it is a way of directing attention away
from those who remain the most at risk, the most in need.
Of course it shouldn’t be, and this wasn’t the intention of
those who were raising these important points at New Directions. But it’s maybe a way of responding to the
cuts. It’s difficult to legitimately rage
against the cuts that are hitting the sector under the guise of a neutral,
research-led approach. However, it’s
perfectly possible and reasonable to point to how current provision isn’t
universally effective, and doesn’t meet the needs of all groups in society. And perhaps there’s something positive about
focusing on groups that do have some political capital in society: older people
and the middle class. The current state
of the sector is, of course, a political decision (at both a local and national
level), and so it will require a political solution. Maybe I should learn to stop worrying and
love the criticism.
But the running theme of the conference was to emphasise
complexity, or nuance, ahead of simple ideas.
To look at the individual nature of the people involved in treatment and
commissioning, to think beyond orthodoxy, beyond the disease model of addiction
to more complicated, entangled idea of choice within constraints. And that’s why I’m not sure I can stop
worrying and simply love this nuance.
Simple ideas are attractive and easily understood. ‘It’s complicated’ is a much more difficult
sell.
Tony Moss
suggested that if the Addiction Theory Network wants to replace the disease
model, then it needs something to replace it with. If we trace the history of thinking about
problems related to alcohol there is a tendency to see the problem as either
within the ‘demon drink’ (as in much temperance narrative), or within people
who have, as Mark Gilman has put it, have ‘got the spots’ – the people who fit
the AA model of having the ‘disease’ of alcoholism.
If the model being presented instead emphasises that both
structure and agency are implicated, then this is, unfortunately, quite simply
a more difficult idea to communicate.
And therefore, as so often, we come back to that difficult
conundrum in relation to policymaking and public engagement: how much to
participate in what is effectively a game, where the ‘winning’ positions and
answers are not necessarily the ‘best’ or ‘most true’. And there, just as with the question ‘what
is addiction’, I don’t have any easy answer.
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