I spent Thursday at the annual conference of the New Directions in the Study of Alcohol Group. This is always excellent, and never the same. The tone and the themes are always driven by the people speaking and those attending, though it retains an open and forgiving atmosphere towards curious and uninformed people like me.
Throughout the day, there were some common themes that struck me. I’m not quite sure how I can link them together coherently (or even if I should – perhaps that would be a misrepresentation) but I’m going to do my best here.
(I haven’t mentioned everyone who presented by name, but all the presentations were fascinating, as well as the comments from the floor. Although I don’t talk about them in detail here, I found the presentations by Tim Leighton and Josie Soutar particularly interesting and useful, as they talked about the practicalities of delivering effective treatment services. To find out more about the conference, check out #NDSAG2018 on Twitter.)
Although it probably reflects my interests and prejudices, I felt that several of the presentations were arguing against the drawing of clear lines. If this sounds abstract and meaningless, I’ll give a couple of examples. James Morris and Claire Melia spoke about the language used by clients and professionals: is it the same, and does this make a difference? Does the language of ‘alcoholism’ serve to exclude people who would benefit from support just because they don’t identify as ‘alcoholics’?
James suggested that we’d do better to understand problems related to alcohol as being on a spectrum. This would allow the full range of people who might benefit from help to have a way of talking about their issues, which makes it more likely they will identify these.
Meanwhile, Claire was pointing out that a key element of recovery (and this was echoed by other speakers) is having a kind of ‘in-group’ identity. That is, people do self-identify as being in recovery, and the social element of this is crucial.
But how are these consistent? If we take away the idea of a defining ‘disease’, or a clearly defined group with a ‘problem’, and replace it with the idea that everyone is somewhere on a spectrum, how can there be a neat group identity? What would separate someone who had stopped drinking having had a physical dependency from someone who had decided they were drinking a bit over the recommended limits and did a programme like One Year No Beer? How could you have a strong in-group identity if we’re all on a spectrum? Does that matter?
And it wasn’t just the idea of having a spectrum of problems that produced this uncertainty about identity and dividing lines; the same thing could be seen with the potential solution or end point to these problems. I was thinking maybe there’s a clearer sense of group identity through the treatment process. Certainly in the field it can feel like there are tribes of fellowship supporters and those who advocate a more cognitive approach, even if it still involves groups, like SMART.
But the discussions made it clear that most people are not actually signed up to a single, coherent philosophy or ideology. Instead, they behave like magpies in terms of recovery/addiction discourses and ideas, taking a creative and flexible approach and picking up what they find useful and acceptable from any particular approach and leaving the rest. So as David Best described, you can find people who step out of a therapeutic community and then go to AA meetings, despite the fact that these two approaches have quite different understandings of the nature of the problem a person is likely to be facing, and how this is best dealt with. This shouldn’t really be surprising. It’s odd to find anyone whose actions (or stated beliefs) accord precisely with any given ideology or belief system. Even Marx, famously, maybe wasn’t a Marxist.
But if it’s not about what ‘problem’ you have, or what treatment you’re receiving, perhaps there’s a group defined by where you end up.
The subject of the conference was ideas of recovery, and I wondered whether, if we couldn’t hang onto an in-group identity of recovering from something clearly defined (like ‘alcoholism’) then maybe the key is in the what you’re recovering towards. This was certainly important for plenty of speakers. Being in recovery meant making social connections and contributing to a community – and this provides a sense of identity and wellbeing, as powerfully explained by Simon Morgan.
But as so often when this comes up and people try to define it, I was struck by the universality of the concept of recovery. What I mean by this is that when people spoke about recovery, they were talking about something that could be applied to everyone’s lives, not just people with an identified ‘addiction’ or substance use disorder.
David Best referred to recovery as a search for ‘eudaimonia’. This is a term from Aristotle that I’ve written about before, and although it’s generally translated as ‘happiness’, it really means something like ‘fulfilment’ or ‘flourishing’. Recovery, he suggested, represents a shift from ‘hedonism’ (pleasure-seeking) to something more rounded and whole (‘eudaimonia’).
Apart from the fact that I’m suspicious of anything that distinguishes pleasure from fulfilment, given that we can’t as a human race (or even society) agree on what a fulfilling life for a person looks like, this has some wider implications for what recovery might mean and how it might apply to thinking about substance use. The definitions of recovery being discussed really amounted (as the use of the term ‘eudaimonia’ suggests) to a whole life philosophy.
This raises the question not just whether there’s a tight enough group defined, but whether there’s even any point thinking about substances. And Tim Leighton pointed out, reporting on his research with staff and service users, that most people don’t talk much about substances in describing what’s good about treatment; they’re more likely to refer to trust between each other and having developed a new set of values and priorities. A key part of this isn’t thinking about substances so much as finding alternative ways to process other emotions, to change the standard response from being that someone would just pick up a drink to cope with a particular situation.
And here’s the rub: if we’re interested in helping people to lead fulfilling lives, through processes of trust and developing internal conversations, what has this got to do with alcohol? As James Morris suggested, wouldn’t we all benefit from some psychotherapy?
(And this is before we start to think about how problems where alcohol is implicated often have their roots (and solutions) in issues around employment, housing, education and personal relationships, rather than the simple chemical substance of ethanol.)
So were we all really attending a discussion of New Directions in the Study of Alcohol, or just New Directions in the Study of Life? I started to wonder whether we’re looking at this right. If it’s all shades of grey, then why are we so keen to draw dividing lines?
Writing this I’ve remembered my facetious claims as a student that basically everything we study is sociology (well, at least the humanities and social sciences). History is just the sociology of the past. English is just the sociology of literature. Economics is just a specialised branch of sociology. But all I really meant was these were subjects that were studying people and societies. Sure, if you take that broad a view it’s all sociology, but what’s the point calling it that? It’s just semantics and it doesn’t get us further because we’ll probably need to specialise to study these things.
Why are my student pretensions relevant? Well, the same applies to studies and treatment of alcohol and other drugs. Yes, we can say it’s all a spectrum and it’s shades of grey, but we’ll still have to draw some lines somewhere. Those lines will be imperfect – and we need to remain conscious of that and not start seeing them as the truth, or the tail wagging the dog. But we do need them in some form.
But there’s still an element of this that makes me wonder about how many of those lines we really need, and how permeable they ought to be. That is, it was noted that in general there isn’t a huge need to separate men and women into gender-specific groups for treatment. And I’ve always said of our local drug and alcohol services that when alcohol users are persuaded to walk through the door, they tend to get significant benefits from sharing group time with users of other drugs. It isn’t the case that we always need separate groups. As Wendy Dossett pointed out in discussion, one of the things people find most useful about having group treatment, and one of the key ways that ‘in group’ identity is formed, is the sharing of shame – of knowing that other people have done the same things you have.
One potential response to this is to say that lots of us have done things we are ashamed of, whether when dependent or intoxicated on a substance or neither. If we’re all sharing this idea of ‘eudaimonia’ or the good life, and it’s meant to entail human connection, why is it limited to those with substance use issues? Is the ‘treatment’ we provide really only for those who have a substance use disorder?
I don’t mean to be flippant, and I understand that if we provide something for everyone, we probably provide something for no-one. And there’s certainly a policy case to be made that having some elements of work ringfenced can be protective, preventing particular workstreams simply being co-opted into a wider mainstream concern.
But all the same, I wonder. What makes this about alcohol? What makes recovery something specific to our ‘sector’? How does it relate to mental health? And how does treatment relate to housing, employment and personal relationships, which we know are so influential? And at what point does talking about developing a different way of living, a different way of organising society, stop being a discussion of alcohol treatment and policy and simply become a political project? Is that what we should actually be doing as professionals – campaigning for a different social and economic structure? Here’s to New Directions in the Study of Life.