Identity crisis

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mike ashtonUK governments agree that above all what they want out of treatment is ‘recovery’. Some of the most marginal, damaged and unconventional of people are to become variously abstinent from illegal drugs and/or free of dependence and (as Scotland’s strategy put it) ‘active and contributing member[s] of society’, an ambition which echoes those of the UK government dating back to the mid-2000s for more drug users to leave treatment, come off benefits, and get back to work.

Similarly, in 2008 experts brought together by the UK Drug Policy Commission agreed that the process of recovery is ‘characterised by voluntarily-sustained control over substance use which maximises health and wellbeing and participation in the rights, roles and responsibilities of society… a satisfying and meaningful life’.

Potentially these agendas pose treatment a daunting task – achieving a kind of redemption in lives which among the caseloads of publicly funded addiction services are often far from satisfying and meaningful.

Shift ground from illegal drugs to tobacco. Would you say someone who has stopped smoking but hasn’t found a job, is still on benefits – maybe even offending – and who remains at a loss for meaning in life, has failed to recover from their addiction?

But perhaps there are good reasons why these wider issues intrude for the more socially unacceptable addictions. In the 1970s Lee Robins was commissioned by the US government to help prepare for the looming avalanche of addicts created by the war in Vietnam, where heroin was accessible and widely used by US soldiers. That avalanche never materialised, and the returnees barely troubled US treatment services. However, the few who did resort to treatment exhibited the classic pattern of multiple problems and post-treatment relapse.

Reflecting on the implications, Robins argued that ‘drug users who appear for treatment have special problems that will not be solved by just getting them off drugs… It is small wonder that our treatment results have not been more impressive, when they have focused so narrowly on only one part of the problem.’ Unlike most of the soldiers, the drug use of addiction treatment patients is entangled with social dislocation and multiple problems, which unless addressed will repeatedly precipitate them back into addiction.

In Vietnam, soldiers from conventional backgrounds turned to heroin to combat boredom and depression, pass the time, and to better tolerate the rule-bound constraints of army life from which there was no escape. According to psychologist Bruce Alexander, for the same kind of reasons, caged experimental rats of the 1960s compulsively pressed levers to get drugs in experiments thought to prove these substances were inherently addictive.

Not so, argued Dr Alexander, demonstrating in his Rat Park study that given a stimulating social and physical environment which allowed the rats to be what rats naturally are – productive, active and social – they consumed far less morphine. In this environment,even physically dependent rats would avoid morphine.

From this perspective, treatment may be part of the solution, but conceivably also part of the problem. Although those who later become addicts often start with few personal, social and economic resources, the little they do have will be eroded by criminalisation and social stigma, and by services that explicitly or inadvertently encourage the adoption of an addict identity – processes which further divorce patients from supports which preclude dependent substance use or help us lever ourselves out if it happens. The ladders are hauled up, blocking a return to normality – a chronicity laid at the door of the addict’s supposedly chronic, relapsing condition.

But accepting the identity of addict and patient gains access to the micro-world of addiction treatment services, in which (at their best) the addict is accepted and made the focus of caring attention and an optimistic assessment of what they might become, moving them beyond an addict identity rather than reinforcing it. The problem is that it is a micro environment, and the effects typically erode on leaving.Rat Park

Dr Bruce Alexander demon­strated in his Rat Park study that, given a stimulating social and physical environment which allowed the rats to be what rats naturally are – productive, active and social – they consumed far less morphine than a controlled, caged population. Graphic by Stuart McMillen from his comic Rat Park – explaining Bruce Alexander’s experiments. ratpark.com

Such thoughts pose practical dilemmas for treatment. If it takes on the recovery challenge, how many fewer patients will we be able to afford to treat, and will that be counterbalanced by slowing the revolving door of relapse and treatment re-entry? Is it simply beyond the reach of any feasible service to create environmental changes of the magnitude that led to rapid, widespread and lasting remission from dependence among Vietnam returnees? Must we set our sights lower and ameliorate the fallout from an addiction-generating society, only modestly if at all accelerating the normal processes of remission? Or would that be a self-fulfilling lack of ambition that fails to grasp the recovery challenge? 

The dilemmas were sharply put by Professor Neil McKeganey in his book, Controversies in drugs policy and practice. He asked whether a ‘revolution’ in treatment was required, which might see dual tracks of intensive help for the (perhaps relatively few) committed to recovery and abstinence, and a holding, harm-reduction track for the remainder. Another way to square the recovery ambition with numbers addicted and diminishing resources would, he argued, be to refuse treatment or truncate it for those not committed to abstinence-based recovery.

Though the solutions may be unpalatable, and abstinence an unnecessary hurdle to the ‘recovery track’ or being considered ‘in recovery’, there seems no denying that getting to recovery as typically defined requires more of treatment services in the face of diminishing resources. Professor McKeganey reminds us that decisions have to be made – or perhaps more realistically, not made quite so explicitly, as we muddle through and make those decisions by default, locality by locality.

This article is based on the Drug and Alcohol Findings Effectiveness Bank hot topic, What is addiction treatment for? Full text with links to documentation at

http://findings.org.uk/PHP/dl.php?file=why_treat_drug.hot&s=dd

Mike Ashton is editor of Drug and Alcohol Findings, findings.org.uk. Look out for his new bi-monthly column in DDN.