Sunday, 25 June 2017

New Directions and the dangers of individualism

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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