Tackling the deficit
Can an entrepreneurial recovery culture overtake an ailing treatment system? Mark Gilman, Peter McDermott and Peter Sheath examine the politics
‘Homophily’: the idea that if you want to stop smoking, overeating and getting divorced, you need to stop hanging around with smokers, fat people and divorcees. If you sit in the barber’s chair long enough, you’ll eventually get a haircut. If you’re seeking recovery it makes sense to hang around other recovering people.
Mutual aid groups are the obvious place to meet those people, but if you do throw yourself into recovery culture, be prepared to have pre-existing beliefs brutally challenged:
‘I’ve been thinking’
‘Stop it – your best thinking got you here.’
‘Take the cotton wool out of your ears and stuff it in your mouth. You might hear something that will save your life.’
‘Oh and get a job! Any job – it doesn’t matter what.’
Recovery narratives can sound moralistic, conservative and Conservative. Moral relativism is rare among people in long-term recovery. There are right and wrong ways of living. The right way is to get a job, pay your rent and care for your friends and family. The wrong way is methadone, booze, benzos and benefits; watching daytime TV while the state takes care of your kids.
In the aftermath of the general election we noticed something peculiar. There seemed to be a political, ontological divide between two tribes – those affiliated with the harm reduction model, and those affiliated with the recovery model. It didn’t seem to matter whether the person expressing the view worked in the field, or was in treatment/recovery themselves.
Harm reductionists saw the outcome as an attack on the entitlement to remain on long-term sickness benefits. They were supportive of a large publicly funded treatment system, which was threatened by the Tory victory.
Recovery messages were about voluntarism, about the need to take personal responsibility and building community – messages that were completely consistent with those of the Conservative government.
Despite Public Health England’s excellent facilitated access to mutual aid (FAMA) programme, few people make the journey from treatment services to mutual aid based recovery. There are exceptions to this and there is cause for optimism in those areas covered by the new grouping of commissioners for recovery who will find their collective voice via the British Addiction Recovery Group (BARG). The real problem for many community treatment service providers is that they simply cannot live with the uncertainties and risks of recovery:
‘These people – my patients, clients, service users – need me to do something. They might die if I don’t provide medical treatment.’
And of course this is true. Some patients might die if they attempt abstinence-based recovery. Life is a risky business but people with ambition and hope take these risks all over the world every day. Leaving the protection of methadone maintenance treatment may increase the risk of death. But it might also be the way to a brand new life beyond your wildest dreams, where you find jobs, homes and friends.
If successful, you might even create a firewall in the intergenerational transmission of addiction in your families. The question is, where should the responsibility for that decision lie? With the commissioner? With the service? Or with the patient themselves?
Again, this risk-taking, entrepreneurial approach to recovery can seem conservative and Conservative and at odds with the risk averse, managerial state bureaucracy where artificial targets, massaged figures and management speak replace experience, strength and hope.
At the moment we have a bureaucratic system measuring inputs and outputs such as access, retention and completion of treatment. In order to get a clearer picture of what drug treatment is actually achieving, we need to be measuring real world social outcomes such as jobs, homes and friends.
Take Successful Sid. Sid accessed methadone maintenance treatment as a heroin addict within days. He was retained there for years and left over six months ago. We can be sure that Sid won’t be returning to treatment because he is dead. People like Sid aren’t dying from acute opioid overdoses, they are dying from chronic physical health problems exacerbated by cheap alcohol – which he started drinking while in treatment.
It seems essential that we continue to look at which parts of the drug and alcohol treatment system work, and which parts are failing. The bulk of what happens in recovery actually happens outside of services – outside the formal treatment system.
Asset based community development (ABCD) has become something of a buzzword of late, but it is happening – often without any formal support or recognition. One strong example of a project based on ABCD principles is Jobs, Friends & Houses in Blackpool. It isn’t a treatment programme, but a business and a great example of a strengths rather than a deficits-based approach to the issues of drug and alcohol dependence.
At the UKRF conference in September, David Best argued that addiction/recovery are human rights issues, and the human rights deficit is most clearly shown by the exclusion of recovering people from the labour market. Programmes like Jobs, Friends & Houses provide an important model for how we can start correcting that deficit, but that’s just a single programme, in a single town.
Every year, thousands of people make the transition out of treatment into recovery in a very quiet, unsung way. Many want to reach out and offer the opportunities they have created for themselves to others seeking recovery who don’t want the formality of treatment or mutual aid within which to do it. Their politics is also probably more in line with the Conservative model of the Big Society, but rather than getting bogged down in labels and ideology, they just get on and do it anyway.
It’s always sad to see resources contracting in a field that you care about, but the truth is, drug treatment has been living high on the hog for much of the last 20 years. It’s going to be interesting to see the extent to which the reduction has an actual measurable impact on outcomes.
For the future though, we in the field need to start building on and making best use of those unpaid, unsung heroes who are delivering recovery both inside and outside the formal treatment system.
Mark Gilman is managing director of Discovering Health, www.discoveringhealth.co.uk; Peter McDermott is a policy professional and service user activist and Peter Sheath is senior associate with Emerging Horizons