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Recovery – why stop at addiction? Guest blog by Paul Molyneux

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Paul Molyneux - Recovery - why stop at addiction?Although a mental health nurse by trade, I’ve worked in community drug and alcohol services for a number of years. Not so many years though. I guess you could say I’ve only been a part of addiction services in the ‘recovery era’ – the days where client retention was the goal, and methadone maintenance and harm reduction was the only party in town, seem like a distant memory from where I’m sitting. And while substitute prescribing and harm reduction are still useful and potentially lifesaving tools, it is the tools of recovery that are now utilised by services.

Recovery Equals Hope

While there’s ongoing debate about exactly what recovery means, as an outsider looking in (I’m not in recovery myself), at its most visceral, ‘recovery’ equals hope; hope that things can change, and change for the better. Indeed, one of the benefits of mutual aid is the chance to see, through positive role models, that change is possible (perhaps in contrast to the same old faces clients see in waiting rooms up and down the country).

Coming from the field of mental health, the prominence of recovery in drug and alcohol services made for a refreshing change. It wasn’t that long ago that I was a student nurse, and while there was the occasional lecture that nodded its head towards the possibility of recovery, working in the field I never got the impression that the message had seeped through to those working in difficult conditions at the coal face. Of course, things aren’t black and white, and I understand that there have been great strives to improve many aspects of patient care. Nevertheless, having spoken to a psychiatrist with recent experience of working within mental health services, it appears that there’s still work to be done.

Parallels

Addiction and mental health disorders regularly co-occur; one often precipitating the other. Having worked within both fields, I’ve often thought of the parallels between the two.

Both appear to suffer at the hands of a negative media portrayal, with scaremongering, stereotyping, and labelling, helping to promote stigma and an ‘us and them’ attitude in the wider public. Rare is it to find a positive news story about mental health or addiction.

Perhaps the most intriguing similarity exists in the use of medication. Through the 1990s, the ‘chemical imbalance’ theory of depression (in part propagated by the pharmaceutical industry) was ubiquitous. With hindsight, most agree that the theory was a gross oversimplification to explain a complex and multifactorial disorder, but the implication at the time was that medication was the only answer and possibly needed to be taken for life. While for some with depression it may have been the answer, for others it may have closed the door to alternative treatments and a chance of recovery without the need for long-term medication. The parallel between this and the implementation of methadone maintenance is stark.

Where Are They?

In relation to schizophrenia, psychiatrists often talk about a ‘rule of thirds’: a third of patients will remain chronically unwell despite treatment; a third will respond somewhat to treatment, and a third will make a full recovery. Of course these figures are only a rule of thumb, but given that schizophrenia will affect around 1 in 100 people, it leaves the possibility that around 200 000 people in the UK have recovered from the disorder. Add in the many who have recovered from conditions like anxiety, depression, and PTSD, and you can see there might be a very large, untapped resource out there.

Through the spectrum of addiction services – from harm reduction to recovery – there exists a significant portion of the workforce who have experienced one form of dependence or another; many climbing through the ranks into positions of senior management. Given the oft-quoted statistic that one in four will experience some kind of mental health problem, it is more than conceivable that a significant percentage of mental health practitioners have experienced mental illness themselves…and presumably recovered. And yet, many remain hidden. Is this a reflection of the stigma associated with mental illness, or perhaps a culture where is self-disclosure is discouraged?

So What’s Happening?

From a UK perspective Dr. Phil Barker, a nursing theorist, has long advocated for a recovery model within mental health services. Indeed, Barker tips his hat to AA who he sees as the father of the mental health recovery movement. His concept of the ‘inevitability of change’ is a message of hope and a central pillar of his ‘Tidal Model’ of nursing (Barker, 2000). The model was developed in the mid-1990s and, although it has featured in mental health nurse training for a number of years, I’m not sure it’s seen widespread implementation. That being said, mental health services have developed the role of so-called S.T.R. (Support, Time and Recovery) workers with the idea that they “will provide support, give time to the service user, and thus promote their recovery” (NHS Careers [no date]). The fact that recovery is even mentioned is a huge step in the right direction.

In the U.S. and Canada, the recovery/consumer movement is apparently far more prominent, with radio programs and Mad Pride marches (although there’s definitely an anti-psychiatry flavour to some of their messages). In 2002, it was estimated that there were 7467 mental health mutual support groups and self-help organisations in the United States (Goldstrom et al., 2006). Perhaps this is a reflection of healthcare provision (or lack of) in America.

Back in the UK, organisations such as MIND and the Depression Alliance, and online communities, do a fantastic job of promoting the possibility of mental health recovery through peer support, but are statutory services doing enough to link service users to these potentially life changing resources?

Summary

Within the treatment of addiction, it should never be a case of either harm reduction (including O.R.T.) or recovery. The two can co-exist. Similarly, within mental health treatment, the implementation of a recovery orientated treatment system would not necessarily substitute the need for medication or other traditional interventions (I’m not advocating an anti-psychiatry viewpoint). We might not see a drastic improvement in the remission rates of mental disorders, but we may see improved treatment outcomes, increased social functioning, and reduced stigma.

The recovery movement has brought about drastic changes to the provision of addiction services within the UK. Although there’s still a long way to go, most would agree that things are moving in the right direction. But if the message of recovery is one of hope; that change is possible, then why should we restrict the message to the field of addiction?

[Paul Molyneux is a nurse working in a alcohol and drug service in the North West of England]

Barker, P. (2000). The Ten Commitments. Available: http://www.tidal-model.com/Ten%20Commitments.htm. Last accessed 7th Sep 2014.

Goldstrom, I., Campbell, J., Rogers, J., Lambert, D., Blacklow, B., Henderson, M., Manderscheid, R. (2006). National Estimates for Mental Health Mutual Support Groups, Self-Help Organizations, and Consumer-Operated Services. Administration and Policy in Mental Health and Mental Health Services Research. 33, 92-103.

NHS Careers. (No date) Support, time and recovery worker. Available: http://www.nhscareers.nhs.uk/explore-by-career/wider-healthcare-team/careers-in-the-wider-healthcare-team/clinical-support-staff/support,-time-and-recovery-worker/. Last accessed 7th Sep 2014.

    13 Responses to "Recovery – why stop at addiction? Guest blog by Paul Molyneux"
    1. Anon says:

      Thanks for this thoughtful blog.
      I wonder if you could say more about the experience of having STaR workers in the treatment system. it sounds like a more formally defined volunteer role than many and I am interested to know how it works in practice.
      Thanks

      • Paul Molyneux says:

        Many thanks for reading the article.

        I have only limited experience of working alongside STR workers, but they seem to be supportive individuals who can take a more ‘holistic’ approach to patient care. …Basically, someone who doesn’t have a role in tinkering with medication (like a psychiatrist or CPN) or delivering psychotherapy (like a psychologist or counsellor). It’s worth pointing out that it is a paid role (band 3, I think) and while some may have a service user background, it is not a prerequisite of the job (which perhaps differentiates it from some of volunteer roles within addiction services).

        I’d be interested to hear from others with more experience of the STR worker role.

    2. Innocent Abroad says:

      I think we need to understand what recovery is and what it isn’t. In terms of substance abuse it isn’t cure: it’s abstinence + management of the emotions through – what, exactly? I put a query here because the history of 12-step and other programmes is one of development. They came out of religious practice, and then outgrew it. Which poses another question, about the relationship of religious practice to mental health. How do you tell a respectable religion from a crazy cult? By weight of numbers? There aren’t that many Quakers, but I doubt Paul Molyneux – or anyone else – would want to call them a crazy cult.

      Mutual help needs direction – if it didn’t the NHS would pull its therapists out of therapeutic groups once they’d got them going. Otherwise they may well engage in collective relapse, as the women’s commune in Jane Campion’s “Top of the Lake” appears to do.

      This is not to say that we, as a society, do not need to engage far more closely with depression (substance abuse is merely a cloak for this or some other mental illness, but my experience in AA leads me to believe that depression is the overwhelming cause of substance abuse) – it is, after all, costing the country a fortune. I have no idea what the role of the recovery model might be in that engagement.

      • Paul Molyneux says:

        Hello Innocent Abroad.

        You raise some interesting questions and I’m not sure I have the answers, particularly in relation to how we role out a recovery model within mental health. What I would say is that we should avoid the politicisation of a mental health recovery model, which may serve to alienate some fantastic workers (and service users) within the existing treatment ‘system’.

        Interesting you mention the Quakers. As I understand it, they played an important role in the development of recovery communities down the centuries. I think The Retreat in York was set up by the them?

    3. Mark Gilman says:

      Fantastic blog. Thank you Paul. I have a dream that one day everyone entering biological, medical, clnical, psychological treatment will be made fully aware that for many people (“you may well be one”) the solution will be social and based on the 5 ways to well being. Who do you CONNECT with? How are you GIVING? How ACTIVE are you? What are you KEEPING LEARNING about? What are you TAKING NOTICE of?

    4. alison says:

      The recovery movement is alive and well in mental health and has been for some decades – see for example the ImROC website (implementing recovery through organisational change). Ironically the fact that recovery has been usurped by services (as distinct from being survivor led) in the UK has proved controversial.

      • Paul Molyneux says:

        Hi Alison,

        Thanks for the comment and highlighting this very interesting organisation. Their “Recovery Top Tips” have many similarities to Barker’s Tidal Model that I highlighted in the article. I’d like to hear other’s experiences of how they’ve worked with this organisation. I see they’re already working with a number of Mental Health Trust in England.

        You last comment is very interesting. I don’t think it’s necessarily about statutory services ‘taking over’ recovery and implementing their own brand of a ‘recovery movement’. I’d suggest it’s more a case of services utilising the existing support that’s out there; actively trying to encourage people to engage with it, in a similar way that someone walking through the doors of a drug and alcohol service is now encouraged to try AA or SMART Recovery. I’d caveat my next comment by saying that the last time I was in mental health services was in 2010, but I didn’t see this happening back then.

    5. Jo says:

      Great blog Paul – we definitely need more promotion of mental health recovery in the UK.
      I have learnt so much from mental health recovery and its actually been around in the UK much longer than drug & alcohol recovery. All over the UK there are well established peer led networks which are extremely vocal and powerful recovery activists.

      The Hearing Voices Network meeting which are peer led & a massive international network for voice hearers are great to be used hand in hand with mutual aid. I have linked in with them when I worked at the Chapman Barker Unit and they are a breath of fresh air for people who have been isolated and distressed about their voices. They are very empowering and a great recovery network.

      Ron Coleman has a great recovery website, as does Rufus May – both have voice hearing experience and work in the field. Asylum Associates advocate for democratic psychiatry and they publish a magazine thats interesting – you’ve probably heard about it in your nurse training described as anti-psychiatry. If you want evidence Maurius Romme & Sandra Escher have done outstanding research and writings on voice hearing.

      CBT for psychosis gives us some great models to work with such as Stress Vulnerability Model and Coping Strategy Enhancement. Voice dialogue is another model which is interesting to read about.

      There is a massive wealth of mental health recovery to tap into and learn from and I was happy to see your blog Paul as mental health is often sidelined and as we know seriously underfunded.

      Let’s continue to champion mental health and keep talking about it!

      • Paul Molyneux says:

        What a fantastic comment Jo! (I believe I’ve used a number of your ITEP maps)

        Yes, Robert Whittaker’s ‘Mad in America’, does a great job of describing the history of the recovery movement dating back to the 1700s – long before AA!

        I didn’t know CBU had used The Hearing Voices Network – what a brilliant resource for patients to access during their admission. The beauty of a network like this that it can help to normalise experiences such as hearing voice, of which there is evidence (by Romme and Benthall, I think?) to suggest it’s far more common than people think.

    6. alison says:

      For more on recovery in mental health see: http://www.scottishrecovery.net http://www.centreformentalhealth.org.uk also the mental health charities all have their take on it – Rethink, Mind, Mental Health Foundation.

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