‘Successful outcomes’ are a key performance measure in drug and alcohol services, but the voices of those going through treatment and recovery in Blackburn with Darwen suggest that ‘success’ is an ever-changing challenge that might mean rethinking services.
Services are driven by performance measures intended to reflect the volume and quality of provision. One key metric is ‘successful completion’ of treatment, defined by a person leaving drug treatment free of drug(s) of dependence and not re-presenting to treatment again within six months.
In Blackburn with Darwen (BwD), the local authority public health team – along with Spark drug and alcohol service and Roots Community (who deliver collaborative treatment and recovery services) – recognised that in the pursuit of ‘metrics’ we can lose sight of what it can really mean to build success in the treatment and recovery journey.
To better understand people’s experiences, the public health team commissioned facilitator Dr Gavin Turnbull to work collaboratively with staff from Roots Community to explore the views, experiences and opinions of those going through treatment and recovery. ‘We conducted a series of group discussions with people at different stages and with varied experiences of treatment and recovery – some abstinent, some not – to discuss what ‘success’ meant to them,’ says Gavin.
Those involved were compensated for their time and expertise and were also invited to take part in developing findings. This follow-up process explored a further question: ‘What would a good service look like with this new understanding of success?’ The project also held a session with local practitioners to get their perspectives.
‘Six months? …it’s not long enough… somebody could be clean for six months and then on the seventh month they’d have relapsed and then not feel like approaching services again because they’re ashamed and they’re embarrassed.’
Defining success
‘It’s probably fair to say that people didn’t really recognise the formal definition of successful treatment, and responses were fairly blunt,’ says researcher Rolonde Bradshaw. ‘Many people stressed that their treatment journeys were more complex, and often at odds with this definition, and success was about more than substances.’
People’s accounts of their successes and future goals highlighted the different needs relating to drug and alcohol use that can be lost when we talk about targets and metrics. There were, however, shared themes that reflected most people’s experiences and views (see box).
‘It’s important to recognise that success is self-defined,’ says Rolonde. ‘The feeling of succeeding makes positive changes stick, but sometimes services can get caught up in assessments and performance measures and miss the important stuff.’
When discussing how services could respond to a wider understanding of success, one practitioner likened the current approach to being presented a menu where the only dish was ‘egg and chips’… no matter what an individual’s circumstances and needs were, options were sometimes limited. So what would ‘good’ services look like if we were to embrace a wider understanding of successful treatment and recovery’? Nine general themes came out of discussions (see box).
‘Success is a daily thing. It’s a daily thing. It comes in steps. Set yourself a goal. When you get to that goal, set another one.’
‘It’s important to recognise that success is self-defined,’ says Rolonde. ‘The feeling of succeeding makes positive changes stick, but sometimes services can get caught up in assessments and performance measures and miss the important stuff.’
‘I was walking around with my head down… I didn’t want to approach anybody, I didn’t want to speak to anybody. I was stood in a corner drinking cider, smoking crack. And now I can walk around the street, sit down on a bench, have a cigarette and I can greet people where at one point I wouldn’t have done that.Â
So to me, I think success varies in terms of where you are, where you’re at.’
When discussing how services could respond to a wider understanding of success, one practitioner likened the current approach to being presented a menu where the only dish was ‘egg and chips’… no matter what an individual’s circumstances and needs were, options were sometimes limited.
So what would ‘good’ services look like if we were to embrace a wider understanding of successful treatment and recovery’? Nine general themes came out of discussions (see box).
Participants identified the importance of listening to perÂsonal circumstances, naviÂgatÂing a suitable combinÂaÂtion of interventions and support and reviewing progress, as well as recognising successes and updating goals. A single assessment at the start of treatÂment was rarely seen as effective in addressing changing needs.
‘Some people’s successful treatment journey could be different. One person could go through a service and pick up skills to live a productive life on their own, and not be involved in other services, whereas other people might need different referrals to carry on for a bit longer.
Everyone’s different.’
People had different exÂperÂiences of services, some reporting that they were experiencing a person-centred, tailored treatment, with their worker helping them to navigate different interventions and provision. This wasn’t the case for everyone, raising questions about the variable nature of practice and services across areas.
Conversations also highlighted the importance of social connection and collective activities, both as a way of supporting treatment and recovery goals and as a wider means of building confidence and developing new social networks that are sustainable in the future.
‘Other people might not say I’m successful, I think I’m very successful. I learned from those six relapses – it doesn’t make you a failure just because you have a relapse.’
Smart Development
While services in Blackburn with Darwen were not a specific focus of this work, participants often spoke positively about the collaborative offer in the area. The study has helped to inform the development of a ‘SMART’ offer for abstinence and non-abstinence focused recovery, enhancements to outreach work, and ongoing co-design of provision between services and those with lived experience.
Insights into how metrics and performance interact with organisational culture and service user experience have also helped to inform commissioner approaches across the area.
‘If you have a lapse, if people then look at you and say, “Oh, you fucked up”, you know what I mean, “you’ve had a lapse” or whatever, that can put pressure on a person to go, “Yeah, I’ll fucking go full-blown now”.’
Discussions also raised challenging questions about stigma relating to both relapse and accessing recovery. Relapse tends to be regarded as a failure in our drug and alcohol system, and the performance measure highlights this for people who re-present to service. For participants, relapse was not seen as an unusual element of the recovery journey, though individual guilt and blame could prevent people from seeking further help.Â
There was also concern about ideas of there being a ‘right way to recover’ affecting both drug and alcohol practitioners’ advice and peers’ views of one another going through recovery. ‘We know that when something works for someone, they advocate for it, but we also know that one size does not fit all,’ says Rolonde.
”That term, do you know if you want to sugarcoat it and call it a lapse or whatever?…You’re not back to square one, because basically you still managed to get that amount of sobriety time that you had, let’s just say it’s 100 days, you still managed to do that, don’t want to take that away from you, and all the knowledge you’ve picked up on the way. You’re not losing that knowledge.
‘The challenge in treatment and recovery services is creating the space to listen to the person coming through the door, guiding them through a range of options to achieve long-term, meaningful success.’
