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Addiction and recovery research – time for change

Posted · 15 Comments

Time-for-change

SMMGP has a great downloadable presentation on addiction treatment research. By Jim Orford, it’s a couple of years old now, but it has not lost any of its relevance. I’ve been writing on the problem of lack of addiction research generally and a definite near absence on recovery research. But we don’t want research for research’s sake; we want addiction and recovery research that is asking and answering the right questions. If we were to come at addiction and recovery research from a different direction, would it help us in a way that traditional approaches have not?

Orford is a Professor of Clinical and Community Psychology at the University of Birmingham. He sets out some of the problems with existing research – why it ‘fails’:

  • It assumes a technological model of treatment
  • It adopts a narrow focus on time-limited professionally dominated treatment
  • It uses an out of date, restricted definition of science and knowledge production

Technological model of treatment

He make a very relevant point around the ‘Dodo Bird Effect’ – the outcome equivalence paradox which views the therapist in an addiction treatment setting as a technician delivering a ‘treatment’ and neglects what we think we know is at the heart of helping people move on – the quality of the therapeutic relationship. So we measure the treatment as the dominant intervention, rather than the personal relationship. The problem with this, argues Orford is that many treatments end up providing much the same kind of outcomes (think Project Match).

His tentative conclusion:

Well-delivered, credible, named treatments are, in most important respects, the same, which would account for supposedly different types of treatment having equivalent outcomes.

Professionally dominated treatment

The problem with professionally dominated treatment is that it tends to ignore professionally unaided change (or, in my experience, resists it); ignores the settings and systems in which treatment is embedded; neglects wider social networks like family and community resources and defines outcomes narrowly. If recovery takes place more in communities than in clinics we are going to miss the impact of community recovery capital on outcomes, something I touched on before.

Restricted definitions of science and knowledge production

Here lie dangerous pitfalls. Research can miss the importance of culture and assume that the findings will be universal. Orford lists more problems:

  • Which assumes research is value-free and researchers are neutral
  • Which privileges top-down expert theory over tacit, implicit knowledge
  • Which ignores the patients view

These chime true for me. The value of lived experience and of recovering people, peer supporting in services has largely been unrecognised. What the patient wants can be lost in delivery of what ‘the evidence’ says works. “Successful” treatment can be one where the patient never reaches his or her goals, but agreed outcomes are still achieved. The service may end up more satisfied than the patient.

In addition there are amazing things happening in recovery communities, in mutual aid groups and in family support services, some of which are peer-led. This is community inspiration, asset building and growth and it is largely not being captured.

Solutions

The prof is not just identifying the problem; he has some suggestions:

  • Stop studying named techniques and focus instead on studying change processes and developing good addiction change theories
  • Study these processes within broader, longer-acting systems of which treatment is a part
  • Bring the science up to date by acknowledging and using the variety of available sources of knowledge (e.g. qualitative research, action research and participative research)

The part that other recovering people (peers) play in recovery from addictions is becoming clearer, at least to those who have eyes to see it. Community recovery capital is on the radar a bit more. Those of us working in treatment need not be afraid of acknowledging that there is more to getting well than professional interventions. When you ask someone in long term abstinent recovery what helped them get there, treatment figures, but it’s not necessarily top of the list and the technical aspects of treatment will hardly be mentioned.

What will be remembered is how kind professionals were, whether we listened to the story, empathised with the struggle and kept faith in them, even when the client struggled to believe in his or her self. In other words, exactly the sort of stuff that traditional addiction treatment research doesn’t measure.

It’s time for change.

    15 Responses to "Addiction and recovery research – time for change"
    1. Anon says:

      Thanks for another interesting read. I think that the impact of research priorities is far too little thought about – it has a real impact on spending priorities, notions of essential and “add on” care and privileging particular approaches to addiction.

      Medication (researched by drugs companies and medics) HAS to be delivered by right. Structured psychological therapies (researched by psychologists, delivered by registered professionals and with relatively small differential impact from one manual to the next) is essential. Community development, peer support and social networking (delivered by community development workers and those in recovery)…would be nice if we could afford them.

      • djmac says:

        I think this is right – the sorts of things that get priority in research terms are professionally led interventions or pharmacological treatments. Social networking, peer to peer support and the impact of positive influences in communities less so.

        • Anon says:

          I agree, but my point was that this in turn has an impact on the treatments/ interventions actually prioritised for delivery.

    2. Innocent Abroad says:

      Professional domination? Ay, there’s the rub.

      If we (as a society) don’t create a professional class of treatment workers, we aren’t taking the problem of addiction seriously, and if we do, we’re creating a special interest group.

      A few years ago I developed chest pain. I wasn’t prepared to reveal this to my GP while I was still smoking (nicotine), so I stopped first – I discovered that the craving disappeared in the time it took to eat an olive (which provided my brain with a counter-stimulus, as it were). Was my GP pleased? Not at all – I’d diddled him out of a capitation fee going help in me stop smoking.

    3. Anon says:

      A related issue, in my mind at least, is the paucity of practice based evidence – having identified through the flawed reasoning you describe, the evidence based practice it becomes axiomatic that when delivered it must be effective so…almost the only thing we can say about Scottish drug and alcohol services is that you get them quickly.

      • djmac says:

        While it’s true that we need to be able to say more about outcomes and the completeness of data is an issue, we can say a little more about what’s going on than just how long people have to wait for treatment. More here.

        I take your point that you only get to see what you are looking for.

    4. Adam says:

      I have the underlying science of what is happening within the relationship in terms of a neurological dialogue so the ‘dodo’ effect can be debunked.

    5. Jo says:

      I’m not sure where the notion of therapists working in drug services has come from, but it certainly isn’t what is happening on the front line. The workforce is changing in drug services with many workers being downgraded and support & STaR workers being employed. The positives of this change is that more people in recovery are getting a first job and a ‘foot up’ in the job market.

      There is a lack of monies for ‘registered professionals’ delivering psychological therapies and I’m not sure it would be particularly useful unless there were mental health issues being dealt with and it was a specific dual diagnosis role. Psychological therapists & psychologists are very sparse in drug services due to the higher banding costs and the application of therapeutic interventions is integrated into case work carried out by very busy lower banded workers. Computer assisted therapy is available in some services using excellent programmes like Breaking Free on line with referrals for more complex psychological therapies being placed with IAPT. Groups are best placed with a mixture of behavioural change, coping strategies, relapse prevention and mutual aid and peer support forums are facilitated and promoted.

      In my opinion, whilst I agree that more research and outcome monitoring change is needed the description of therapists delivering interventions in drug service is an unreal picture of drug services today. Sadly I also realise that quality is dictated by what service you walk through the door of, and that in the past I have worked for effective recovery orientated services.

      • Innocent Abroad says:

        Doesn’t much depend on whether you see drug consumption as invariably abusive behaviour? And if you do (if you don’t, you’re probably not in the recovery “business” anyway) are there any circumstances in which mental illness is not also present – if abusive behaviour is learnt behaviour (it’s hard to understand what else it might be) then the “unlearning” is going to go a long way beyond simply “putting down” the substance or substances.

        When I was in detox, all those years ago, someone asked me what I was going to do with the money I’d be saving. I replied “something tells me I’ll be spending it on a shrink at some point” – an accurate prediction. But it’s not one that most people in detox are able or willing to contemplate. Recovery work is first aid, and that’s all it can be.

        • djmac says:

          Doesn’t much depend on whether you see drug consumption as invariably abusive behaviour?

          Not consumption, no. Dependence, by definition is harmful.

          Recovery work is first aid, and that’s all it can be

          I wonder if your definition of ‘recovery work’ is too narrow. I would say that therapy, if folk choose that path, is recovery work. Anything that builds recovery capital would be. I remember hearing the great addiction researcher, George Vaillant say, after decades of research of addiction and remission, that sadly (he was a a therapist after all) psychotherapy had much less of an evidence base for efficacy than mutual aid.

          • Innocent Abroad says:

            I would not see therapy and mutual aid as either/or. I have used both over the last 16 years (and am now in group therapy which is perhaps a bit of each) and would suggest that for many of us the best path is mutual aid first, therapy later.

            Mutual aid can only take the recovering addict/alcoholic so far. It may, of course, be as far as some – or even many – of us can travel. Each case is different and some people may prefer not to get so well that they can no longer interact positively with their extremely damaged families.

      • djmac says:

        I’m not sure where the notion of therapists working in drug services has come from

        I did wonder about that. I guess residential rehab services maybe, but they represent a fraction of the folk going through treatment. I trialled the Breaking Free Online programme a few years back and was impressed. David Best did a study a few years back looking at the amount of time workers spent on ‘therapeutic’ activity (and not just process). He found that it was pretty low, so you may be right.

        I’m with you on your observation that there are pockets of good practice around. The goal must be to bring us all up to those standards.

      • Anon says:

        i think that this might be a matter of geography with Scotland and England being in different positions – in scotland, while we dont have masses of psychologists we do have a workforce and a treatment offering which very heavily emphasises one to one support delivered by counsellors and nurses using at least some PSI (as well, of course, as medication). The reality may be that those workers have far too large caseloads to actually deliver anything resembling the manualised treatments, but that is the model of care – group interventions, mutual aid, peer support and active linkage to the recovery community are making some inroads into practice but the focus for most interventions is still the one to one “counselling” session by a member of a professional body. The StAR workers model looks really interesting (thanks for drawing it to my attention) but would be very rare in this area.

        • Anon says:

          That said, I do think that long term counselling needs very much to be available for long term work on underlying trauma, dual diagnosis etc and can be very valuable – I just agree that infrequent one to one therapeutic sessions, however skilled and concordant with research manuals, is not as good a first line treatment for serious addiction as immersive exposure to lived recovery experience through mutual aid.

          I would think that even if there were the wherewithal to provide that level of support and there were no other processes to absorb clincal time, but even more so given the reality of the resources available and the need to be cost effective.

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