Some core findings in research on self-change and some implications for practice

1. Some core findings in research on self-change and some implications for practice (with an emphasis on Swedish research and addiction care in Sweden) Dansk Selskab for Misbrugspsykologi Seminar om ’self-change’København, 10 December 2007 © Jan Blomqvist <jan.blomqvist@sorad.su.se>

2. Topical issues in handling addiction problems in Sweden: The alcohol field: Accession to the EU  disarmament of tra- ditional alcohol policy  increasing con- sumtion; perceived need for alternatives The drugs field: Increasing abuse; increasing mortality  ambition to strengthen traditional restrictive policy New interest in addiction care: • New resources for care of ”heavy” abusers (coerced care /”care chains”) • National guidelines for treatment of substance abuse and dependence

3. The state of art of addiction care in Sweden © Jan Blomqvist <jan.blomqvist@sorad.su.se>

4. The official picture of addiction care National Board of Health and Welfare on addiction care (2005): … There are good examples, but … Interventions are often ad hoc and ill planned, and treatment is often interrupted … Intense (but often unsuccesful) treatment attemps alternate with long periods without support … Relapse seems to be the standard outcome of fragmented interventions

5. Some research-based conclusions: • Low professional consensus (ideology; theory; terminology) • Differing views on alcohol and drug problems (the drug addict more alien and worse out) • Large between-unit differences (what you get depends on where you live) • Large within-unit differences (what you get depends on who you meet) • Lacking legal security (coercive care) • Few ask for the client’s own opinion • Everyone is not judged alike – but economy, local traditions, and ideology as important as – or more important than – clients’ needs and whishes • Large resources are spent on a small group with severe social and psychological problems, who turn up repeatedly • Persons with less severe problems / earlier stages / with better social resources are not reached by / reluctant to contact the treatment system (low availability / fear of stigmatisation /low confidence in existing treatment) (E.g., Blomqvist & Wallander, 2004; Wallander & Blomqvist, 2005; Blomqvist et al., 2007))

6. Evidence-based practice guidelines – some pros and cons © Jan Blomqvist <jan.blomqvist@sorad.su.se>

7. Arguments in favour of EBP: • Humanism: - focus on outcome, not on legislation/procedural rules or on ”filling beds” (clients’ welfare, not staff’s comfort or safety) • Certainty: - focus on facts, not personal convictions or beliefs (what actually works, rather than guesswork or ”sunshine stories”) • Utility, economic rationality: - tax payers can’t afford that money are spent on activities that do not effectively solve the problems in question © Jan Blomqvist <jan.blomqvist@sorad.su.se>

8. How ”evidence based” is Swedish addiction care?(National inventory, 2005; ”bearing ingredients”) • Social skills training (32 %) • Ego-strengthening therapy / suport (31 %) • 12-step treatment / Minnesota model (25 %) • Cognitive behavior therapy (19 %) • Solution-focused treatment (16 %) • Social-pedagogical model (responsibility training) (11 %) • Motivational interviewing (10 %) • System-theoretical model (10 %) • Behavior therapy (10 %) • Acupuncture ( 9 %) • ………………… • Community Reinforcement Approach – CRA ( 1 %) • ……………….. • About 1/3 of all units offer medicine-assisted treatment

9. Actual vs. recommended methods in Swedish addiction care(”matches” & ”mismatches” with National guidelines, 2007) • Social skills training (32 %) • Ego-strengthening therapy / suport (31 %) • 12-step treatment / Minnesota model (25 %) • Cognitive behavior therapy (19 %) • Solution-focused treatment (16 %) • Social-pedagogical model (responsibility training) (11 %) • Motivational interviewing (10 %) • System-theoretical model (10 %) • Behavior therapy (10 %) • Acupuncture ( 9 %) • ………………… • Community Reinforcement Approach – CRA ( 1 %) • ……………….. • About 1/3 of all units offer medicine-assisted treatment

10. RCTs useful /needed for: • Valid causal inferences • Discarding of ineffective and harmful methods • Basis for resource allocation - aggregate level • However: • The most practiced metods have not been studied in RCTs (what is ”unspecific support”?) • Ever-changing knowledge base (guidelines may be obsolete before publishing) • Moderate effects; control groups change as well • Results at group level not necessarily valid at individual level (but we know little about what is best for whom) • ”Method” explains only part of the outcome variance

11. Dividing the outcome variance pie (Lambert, 1992) © Jan Blomqvist <jan.blomqvist@sorad.su.se>

12. RCTs useful /needed for: • Valid causal inferences • Discarding of ineffective and harmful methods • Basis for resource allocation - aggregate level • However: • The most practiced metods have not been studied in RCTs (what is ”unspecific support”?) • Ever-changing knowledge base (guidelines may be obsolete before publishing) • Moderate effects; control groups change as well • Results at group level not necessarily valid at individual level (but we know little about what is best for whom) • ”Method” explains only part of the outcome variance • Limited external validity (only treated persons; selection and standardization of therapies, therapists, clients)

13. Heterogenous problems:who have been studied and who are treated? RCT-studies Addiction care

14. RCTs useful /needed for: • Valid causal inferences • Discarding of ineffective and harmful methods • Basis for resource allocation - aggregate level • However: • The most practiced metods have not been studied in RCTs (what is ”unspecific support”?) • Ever-changing knowledge base (guidelines may be obsolete before publishing) • Moderate effects; control groups change as well • Results at group level not necessarily valid at individual level (but we know little about what is best for whom) • ”Method” explains only part of the outcome variance • Limited external validity (only treated persons; selection and standardization of therapies, therapists, clients) • Short-term consequences of time-limited interventions (but what happens before, outside of, and after the treatment is also important)

15. Research on ”natural recovery” or ”self-change” © Jan Blomqvist <jan.blomqvist@sorad.su.se>

16. Historical ”natural recovery” issues: • Does ”natural recovery” exist? • How common is ” natural recovery”? • Who are the ” natural recoverers”? • Which are the underlying processes? © Jan Blomqvist <jan.blomqvist@sorad.su.se>

17. ”Self-change” – from ”mis-diagnosis” to ”the natural thing” Some ”classic” studies: Les Drew (Australia, 1968): alcoholism as a self-limiting disease Charles Winnick (USA; early 1960s): ”maturing out” of drug addiction Lee Robins (USA; 1970s): Vietnam veterans stopped addiction at return Past decade: Abundance of ”self-change” studies: Canada, Switzerland, Sweden, Finland, Germany, GB, USA, Australia, Spain and other countries; The occurence of ”self-change” widely recognised (less so for drugs) ”Whether formal treatment is involved or not, ’assisted self-recovery’ is the norm (Blomqvist & Cameron, 2002) Studies of the interplay between environmental influences, formal help experiences and internal processes in long-term recovery

18. Change of perspectives on alcohol problems: © Jan Blomqvist <jan.blomqvist@sorad.su.se>

19. How common is ”self-change”? • Smart (1975): annual rates of ”spontanoeus recovery” from alcoholism: 1 % - 33 % (nine studies) • Waldorf & Biernacki (1979): nine studies on ”spontanoeus recovery” from drug addiction: equally varying annual rates • Sobell et al. (1996) ”natural recovery” the predominant path from alcohol problems • Cunningham et al. (1999) vast majority of ex-drug users never went to treatment However: The prevalence of ”self-change” will depend on how one defines ”addiction”, ”solution” and ”treatment” (Roizen et al., 1978; Blomqvist, 2001) © Jan Blomqvist <jan.blomqvist@sorad.su.se>

20. Three patterns of improved drinking habits – Subjects in a representative population sample who improved risky drinking habits (N= 339/2,862) (Blomqvist et al., 2007)

21. How important is treatment? Proportion who improved their drinking habits without treatment; representative population sample; N= 339/ 2862 • Previous drinking: • Present drinking: • ”Risk consumer” • ”Problem consumer” • Dependent (ICD-10) ”Normal” 94 % 90 % 83 % 72 % • ”Moderate” 85 % 44 % • Abstainer 55 % 48 % 28 % (Blomqvist et al., 2007) © Jan Blomqvist <jan.blomqvist@sorad.su.se>

22. Who are the ”natural recoverers”?(Logistic regressions) Predictors for untreated vs. treated recovery (former dependent drinkers n= 104): - lower degree of dependence (ICD-10) - shorter period with ”risk drinking” - larger social resourses (index) Predictors for – formal and informal – help (all former risk drinkers; n= 339): - higher degree of dependence (ICD-10) - longer period with ”risk drinking” - parental responsibilities (Consumtion in itself – frequency, quantity, frequency 5+ – not significant) (Blomqvist et al., 2007) © Jan Blomqvist <jan.blomqvist@sorad.su.se>

23. One year follow-up of previously untreated problem drinkers Predictors for improvement (logistic regressions): Men: - employed at baseline - treatment - low social pressure to drink past year (”dry” social network) Women: - univesity education - low social pressure to drink past year (”dry” social network) *abstinent or problem-free drinking last 30 days (The AHF-project: Blomqvist & Christophs, 2005; preliminary analyses of 1-year data)

24. Processes of – untreated and treated - recovery(Blomqvist, 1999; 2002)

25. The path into and out of addiction - course and driving forces • INDIVIDUAL FACTORS • (Values, competences , experiences; personal and social resourses) • LIFE EVENTS • (Negative consequences; mundane or dramatic ”turning points”; positive incentives) ”Functional” drinking/ drug use Drinking/drug use as ”central activity” Increasing problems (ill-ness, social, psychological) Connecting problems to use /crisis / insight / wishes to change New social and/or personal identity ”Gains” from a sober life style Handling immediate problems (”resisting”) Hopes; alternatives/ desicion;change attempts • STRUCTURAL FACTORS • (Distributions of material goods; alcohol- and policies; ”governing images”; social policy • RELATIONS • (Relatives and friends outside the ”addiction world”; professional / informal support systems)

26. ”Governing images” of addiction and recovery © Jan Blomqvist <jan.blomqvist@sorad.su.se>

27. Popular images of nine types of addiction Who is responsible for solving the problem?(repr. population survey; N > 1.000): © Jan Blomqvist <jan.blomqvist@sorad.su.se>

28. Perceived chances for ”self change” © Jan Blomqvist <jan.blomqvist@sorad.su.se>

29. Others’ reactions toward addicted people (repr. population sample; N > 1.000): © Jan Blomqvist <jan.blomqvist@sorad.su.se>

30. Implications for practice:EBP in a wider perspective © Jan Blomqvist <jan.blomqvist@sorad.su.se>

31. The challenge: • The official/manifest goal: • to make people stop using narcotic drugs and (ab)using alcohol (Government action plans on alcohol and drugs) • The actual / latent goals: • Diminishing suffering & mortalilty /creating more tolerable life conditions/ relieve some pressure from relatives and friends (Lindström, 1994) • ”Controling the uncontrolable” (Bergmark & Oscarsson, 1988) • Assisting society in ”living with its addicts” (Kühlhorn, 1983) • Given that both aims are legitimate, what could and should be done to • adapt what is done to variegated and heterogenous needs • in a variegated and heterogenous group of people • with a variety of addiction problems?

32. 1. Facilitating self change / helping people help themselves • Counteract moralism and simplistic categorisations. See addiction as a life style problem / ”environmentally responsive behavioral health problem” • Teaching that self-change is possible and how the environemt may help • Options to evaluate own consumption habits / easily available advise / reliable self-help materials (web sites, telephone ”help lines” a s o) • Encouraging different kinds of ”mutual help”- and support groups • Easily accessible / brief / attractive forms of support (no clear border between ”self change” and ”treatment”) • Social policy interventions to create sound alternatives (Blomqvist, 2006; Blomqvist et al., 2007) © Jan Blomqvist <jan.blomqvist@sorad.su.se>

33. 2. Making services attractive and relevant to the large majority of problem users • High availabilty / support on demand (”motivation is perishable goods”) • ”Start where the individual is” • Assessment/planning/choice of intervention in dialouge with the client • ”To each according to his needs” – not ready-made ”care chains” (specific or global interventions; assessment/brief advise/treatment/long-term support) • Continuous follow-up/revision of plans - in dialouge with the client • Broad menue of approved methods and supportive interventions • Cross-disciplinary team(”bio-psycho-social”; joint organisation?) • Co-operation with the environment (other help systems; ”natural healing forces”) (Blomqvist, 1999; 2003; Humphreys & Tucker, 2002)

34. 3. Improving the situation of the ”heavy” addicts or ”chronic cases” –do we need new resources or new ways of thinking? • Some points of departure: • Continuity is crucial: long-term problems require long-term support • No evidence for the benefits of long-term coercive care • No intervention is as influential as ”the natural environment” • Own choice →stronger committement / positive expectations →better outcome • Good relation / working alliance is crucial • Less intense consumption / improved life quality is acceptable goal • ”From intensity to extensity”: • Rather than irregular, intense, and often interrupted interventions (coercive institutions, treatment homes a s o): • continuous, less intense contact (”generic counselor”; personal ”ombud”), varying forms of support when needed, mobilisation/strengthening of ”healing forces” in each person’s life context; swift and adequate interventions in ”acute” situations (Humphreys & Tucker, 2002; Blomqvist et.al. 2007)

35. How to keep the learning process going? Three interpretations of EBP: • The informed practitioner – consulting research data bases for each individual case • The guidelines-directed and manual-abiding practitioner • The pragmatic practitioner – trying to balance scientific evidence, well-documented clinical experience, and clients’ needs and whishes (cf. Sacket et al., 1997) © Jan Blomqvist <jan.blomqvist@sorad.su.se>

36. Pragmatic practice: how to strike the balance? Developing a basis of well-documented clinical experience and professional consensus : Research needs: • More controlled outcome studies (efficacy studies of common techniques) • More efficiency studies of ”promising” methods • More studies of the treatment process and ”common factors” • More long-term, naturalistic studies; user’s perspective; organizational aspects, a s o • Systematic documentation – follow-up – collegial dialouge at the practice level Putting the single client i focus: • Keeping track of the development of the single case (corrections / adaptions to new circumstances / increased motivation / better outcome)

37. How to keep the knowledge process going: Bridging the gap between research and practice • Research: • contribute ’abstract’ knowledge (causes; methods; principles) • (advise practice on documentation and self-scrutiny) • Practice: • (translate and adapt abstract knowledge to shifting concrete circumstances) • Scrutinise, articulate and systematise own experiences • … in dialouge with users/clients… and… • on-going ethical discussions © Jan Blomqvist <jan.blomqvist@sorad.su.se>

38. Some titles referred to: Will soon be able to download from: www.stockholm.se/fou Blomqvist (1999) Blomqvist (2002) Blomqvist & Wallander (2004) Blomqvist et al. (2007)