Mapping routes to recovery and the role of recovery groups and communities

1. Mapping routes to recovery and the role ofrecovery groups and communities Dr David Best Reader in Criminal Justice University of the West of Scotland

2. What Do Eminent International Experts Tell Us? “Addiction is not self-curing. Left alone, addiction only gets worse, leading to total degradation, to prison, and ultimately to death” Robert Dupont Director of NIDA 1993 “As with treatments for these other chronic medical conditions [hypertension, diabetes, asthma], there is no cure for addiction” O’Brien and McLellan, The Lancet, 1996

3. So What Do Clients Typically Get in Treatment (1) – Birmingham review Mean length of last session = 46.6 minutes = One hour and thirty-three minutes per month Or 18.6 hours per year Of which 10 minutes per session is ‘therapeutic’ = 4 hours of therapeutic activity per year

4. Time spent (in minutes) in last drug working session Best et al (in press)

5. Walsall service review • Review of 753 clients • Clients averaged 5.4 contacts in the last 3 months • Average session lasted 34.5 minutes • Amount of contact time per month was: • Community drug team – 69 minutes • Criminal justice – 68 minutes • Shared care – 48 minute Main problems were that services were not differentiated, clients dealt only with prescribing issues and nobody moved on This is prescribing and not treatment This is what happens when maintenance rationale dominates a treatment agenda

6. What has gone wrong with structured day treatment TARGETS Quantity Over Quality Morale collapse & contagion Methadone, wine & welfare Working in a tap factory Methadone based treatment Instrumental working Models of chronic, relapsing condition

7. So what are the grounds for optimism? • Previous outcome studies of rehabilitative services • The premises of a ‘careers’ model and what we can learn from crime • The innovative work carried on in the US about recovery and overcoming stigma • The emergence of a ground-level commitment to recovery in the UK • An opportunity for re-thinking professional roles and relationships • The recognition by policy-makers that treatment is not enough

8. Drug Use Outcomes: Residential

9. What can we learn from the ‘developmental’ model of criminology • Laub and Sampson (2004) follow-up study of adolescents from youth offending institutes followed up to the age of 70 • Key predictors of change were successful relationships and stable employment • Debate is about structure or function – what comes first? • Treatment can act as a turning point if it provides a window of opportunity for change, and there are available resources to sustain and support that change in real-life settings • White (2007): and the concept of recovery communities

10. Sampson and Laub’s Reformatory Sample followed from 15 to 70

11. Sampson and Laub’s Reformatory Sample followed from 15 to 70

12. So what is unique about the careers perspective? • It is generally a model of hope • The Laub and Sampson model rejects a risk factors approach in favour of adult growth • While recognising the ‘chronic and relapsing’ nature of addiction, this is not seen as a life sentence • Key concept of ‘turning points’ • Windows of opportunity for change • The key turning points are psychological and social not biochemical • Links to White’s concept of ‘monocultural’ and ‘bicultural’ social networks

13. Social capital and the implications for treatment “The sum of the resources, actual or virtual, that accrue to an individual or a group by virtue of possessing a durable network of more or less institutionalised relationships of mutual acquaintance and recognition” (Bourdieu, 1992) “Those who possess larger amounts of social capital, perhaps even independently of the intensity of use, will be likely candidates for less intrusive forms of treatment” (Granfield and Cloud, 2001)

14. Natural recovery • Sobell, Campbell and Sobell (1996) reported rates of 75 and 77% recovery without formal help in drinkers in remission. • Cunningham (2000) assessed recovery from a range of substances, and reported that the use of any formal treatment ranged from 43.1% for cannabis to 90.7% for heroin, with 59.7% of cocaine users seeking formal treatment at some point in their recovery journeys. • Bloomqvist (1999) has argued that the allocation of resources and opportunities in life will shape the likelihood of recovery journeys and the options available to people.

15. Personal and social capital – linking psychological and sociological models • What are the resources at a person’s disposal? • What is their stake and commitment to the conventional values of society • Laub and Sampson (2004) – desistance predictors • Attachment to a conventional person (spouse) • Stable employment • Transformation of personal identity • Ageing • Inter-personal skills • Life and coping skills

16. The recovery agenda Alexandre Laudet (2008) “Understanding recovery and identifying factors that promote or hinder it will require a number of paradigm shifts for addiction professionals, including moving from an acute care model to a chronic or long-term approach, and shifting the focus of research and service provision from symptoms to wellness”

17. What are the aims of recovery research? (William White, pers comm) • shortening addiction careers • extending recovery careers • capitalizing on developmental opportunities for recovery initiation • matching individuals to particular types of recovery support • the styles and stages of long-term recovery to provide normative data for individuals, families and service workers

18. The Scottish policy context “A process through which an individual is enabled to move on from their problem drug use, towards a drug-free life as an active and contributing member of society” The Road to Recovery (Scottish Govt, 2008) The report emphasises that one of the key aims is to bring about a shift in thinking

19. Key principles of the Road to Recovery • Recovery is the explicit aim of all services • A range of appropriate treatment and rehabilitation services should be available in each locale • Treatment must integrate effectively with a wide range of generic servicees • There is a commitment to establishing a Drug Recovery Network and to build the capacity of advocacy services

20. So what is our own contribution to the research 1. The end of careers 2. Mapping recovery journeys and communities

21. 1. End Of Careers Studies • Sample of 187 former addicts (alcohol, cocaine and heroin) currently working in the addictions field, from total group of 228 former users • 70% male • Mean age = 45 years • 92% white • Worked in the field for an average of 7 years • First publication looked at heroin users trying to give up Best et al (2008)

22. What finally enabled participants to give up?

23. What enabled people to maintain abstinence?

24. Comparison of drug and alcohol recovery journeys • Compared primary drinkers (n=98), primary heroin users (n=104) and those who reported problems with both alcohol and drugs (n=67) • Former heroin users reported more rapid escalation to problematic use but much shorter careers involving daily use than was the case in the alcohol cohort. • Alcohol and heroin users also differed in their self-reported reasons for stopping use, with drinkers more likely to report work and social reasons and drug users to report criminal justice factors. • In sustaining abstinence, alcohol users more often reported partner support and drug users peer support and were also more likely to emphasise the need to move away from substance using friends than was the case for former drinkers. • Users of both alcohol and heroin were least likely to cite partner factors in sustaining recovery, but were more likely to need to move away from using friends and then to cite reasonable accommodation as crucial in sustaining abstinence. Best et al (submitted)

25. Key qualitative themes • Key role of social learning • Need to complement recovery belief with recovery of esteem and learning of skills • People may move through and beyond mutual aid groups • Incompatibility of treatment and mutual aid pathways

26. Recovery study in Birmingham and Glasgow – mapping the roads to recovery • What are the support group options in each city for people achieving stable recovery? • What are their routes to recovery? • What are the key ‘turning points’ in recovery journeys • How does it differ for abstinent compared to maintained heroin users? • What are the key policy implications?

27. Preliminary Birmingham data • Based on initial pilot cohort – Birmingham service users group who will be the peer interviewers • Mean age – 32.5 (range 24-43) • 80% male, 80% single, 70% white British, 60% have children • 1 homeless at interview BUT 90% lifetime homelessness • 2 working full-time; 1 part-time; 6 doing voluntary work • Only 10% have never had full-time jobs – and have averaged 7.8 years in FT employment, but last worked on average at age 27

28. Preliminary Birmingham data

29. Preliminary Birmingham data • 11 have ever attended NA, 2 other mutual aid groups • 9 are in maintained recovery, 11 in abstinent recovery • Markedly higher self-esteem and self-efficacy in the abstinent than the maintained groups • Maintained group score significantly higher on QoL scale measuring health independence • BUT no differences in depression, anxiety or heroin relapse anxiety

30. Self-esteem and self-efficacy in treatment and recovery populations

31. Emerging qualitative themes • Reasons for stopping include a fear of rock bottom (losing everything), maturing out (tired of lifestyle) and family factors (pregnancy, loss of children and relationships) • Much support for 12 step, peer groups and day programmes • Frequent aspiration to become a worker in the field, and to be a better parent and person

32. Conclusion • Recovery research is better to do – and should be generally inclusive and participative • Recovery is about hope, and about self-determination • The addictions field – practitioners, researchers and policy makers – need this agenda to dig themselves out of the pit of despond and green sludge • This agenda is about de-medicalisation and de-professionalisation • Treatment is generally not very good, not very honest and is definitely not enough • The beneficiaries should be users, families and communities • As researchers we need to be humble about how little we know about recovery

33. Acknowledgements • Jamie Sadler & Tony Mulaney (DATUS, Birmingham) • Birmingham DAAT • Glasgow Addiction Services • Glasgow ADAT • South East Alternatives, Glasgow • Professor Avril Taylor