The discovery of recovery – where did it all start?

mike-ashtonSince 2008 ‘recovery’ has been at the heart of British drug treatment policy. As Mike Ashton reports, it has been used as both an inspirational call to overcome addiction and a justification for limiting treatment

Though the term has a long history associated especially with 12-step-based approaches, the modern ‘recovery’ era in Britain can be dated to May 2008, when governments in Scotland and England presented it as a new dawn, which would reinvigorate treatment services stuck in the rut of preventing harm and crime rather than redeeming and regenerating lives.

In an ‘age of austerity’, commentators have noted that the ambitious rhetoric was not matched by the ‘intensive support over long periods of time needed to become drug free’. Though incorporated in genuine patient-centred advocacy, at a political level, in England ‘recovery’ helped legitimise not intensification, but withdrawal of support, as long-term treatment became stigmatised as impeding recovery. This article offers a reminder of that part of its origins which lay in the imperative to cut public spending and curtail addiction treatment – not to do more, but to spend less. Neglected in the dazzle of the recovery vision, these origins remain active in today’s conceptualisations and uses of the term.

So dominant has recovery become, that it lies at the heart of the treatment themes in Britain’s national drug policies. It features in the titles of both the English and the Scottish strategies, while the Welsh strategy committed the nation to ‘focus our efforts on helping substance misusers to improve their health and maintain their recovery’.

What these strategies meant by ‘recovery’ was not spelt out, but the broad themes were clear: some of the most marginal, damaged and unconventional of people were 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’. Scotland’s ambition echoed those of the government in England dating back to the mid-2000s for more drug users to leave treatment, come off benefits, and get back to work – and become an economic asset rather than a drain.

At first, under Gordon Brown’s Labour government this ambition verged on the brutal. In February 2008 Labour’s UK drug strategy seemed to threaten drug users reliant on benefits with penury if they failed to ‘move successfully through treatment and into employment’. The backdrop was the credit-crunch crisis dating from August 2007, followed in April 2009 by a promise by Conservative Party leader David Cameron to usher in an ‘age of austerity’ to cut the budget deficit.

Though transition out of treatment and into employment was close to what later became ‘recovery’, of the six times that word was mentioned in the 2008 strategy, all but one referred to recovering financial assets from drug dealers, not recovery from addiction. South of the Scottish border, ‘recovery’ had yet to be discovered, but already preparations must have been underway to make it the dominant theme in the May 2008 Scottish strategy. That month too, in England the initial stress on reintegration through employment, enforced by withdrawal of benefits, had in senior government circles morphed into a more appealing label: ‘recovery’.

In this, Labour was not just catching up with Scotland but also with the Conservative opposition. In July 2007 David Cameron’s ‘New Conservatives’ had released the fruits of their addictions policy think-tank. In contrast to Labour’s strategy, ‘recovery’ was the banner for its overarching philosophy. For treatment in particular, ‘The ultimate goal… should be recovery and rehabilitation through abstinence.’ It required ‘radical reform’ entailing a move away from substituting legal for illegal drugs and ‘facing the fact that abstinence is the most effective method’. Not much survived of what would have been an expensive shift to residential rehabilitation and the structural reforms the report saw as needed to pursue recovery. But recovery itself, and the associated abstinence objective and denigration of maintenance prescribing, became embedded in Conservative thinking – and with the advent of David Cameron’s government in 2010, in national policy.

The strands later to be woven into the English version of recovery had, however, been gathering several years earlier, prompted in the mid-2000s by the felt need to make economies in addiction treatment and contain public spending – especially the welfare benefits on which the patients overwhelmingly relied. Though total funding was increasing, per patient funding had been falling for several years when in 2005 an ‘effectiveness’ strategy developed by the National Treatment Agency for Substance Misuse (NTA) complained of the ‘lack of emphasis on progression through the treatment system’ leading to ‘insufficient attention… to planning for exit’. Foreseeing a time when funding would be less available, the agency’s board was told that ‘Moving people through and out of treatment’ would create space for new entrants ‘without having continually to expand capacity’.

Opposing the previous stress on retention – the yardstick on which services were then being judged – in 2007 this new emphasis on treatment exit was given an unwelcome boost when the prevailing crime-reduction justification for investing in treatment was challenged by the BBC on the grounds that treatment should be about getting people off drugs. There was no gainsaying the seemingly incriminating fact that in England in 2006/07, just 3 per cent of drug treatment patients had been recorded as having completed treatment and left drug free. The shock of that challenge and the economising turn away from retention to treatment exit fed through to the following year’s national drug policy. Announcement of a three-year standstill in central treatment funding until 2011 – a real-terms cut when the caseload was expected to rise – further focused attention on squaring the circle by getting more patients to leave as well as enter treatment.

By then firmly linked to the term ‘recovery’, in 2014 the emphasis on treatment exit remained in government circles, eliciting a robust defence from the Advisory Council on the Misuse of Drugs (ACMD) of long-term opioid substitution therapy for heroin users. The following year the Conservative Party’s election manifesto made it clear that the council’s message had been rejected, continuing in the name of ‘full recovery’ to condemn ‘routine maintenance of people’s addictions with substitute drugs’.

Mike Ashton is editor of Drug and Alcohol Findings, This article is abridged from which offers links to source documents and also explores the meaning of recovery and its implications for treatment services.