Defending the palliative care response

Peapod directs us to a compelling article in Drink and Drug News. It looks at professional resistance to the recovery model.

Recovery is a lived experience, and one of the challenges that we face is the recognition that it will mean different things for different people – and indeed will mean different things over the addiction career and the recovery journey. So there is an academic and clinical problem in both operationalisation and definition.

While we should be sympathetic with those who struggle to come up with a consensus, we should perhaps also question their motives in wanting to do so. As Heyman (2010) has argued, addiction is an imbalanced disorder in which, while onset may have genetic and biological bases, there is little evidence that this is the case for desistance or ‘recovery’. As Best and colleagues (2009) have demonstrated for a UK recovery population, people finally recover because of things to do with relationships, families, jobs and lifestyles, and do so in very personal ways.

This is largely outside of the domain of the knowledge, experience or expertise of the psychiatrists, bringing to mind the closing line of the  Tractatus Logico Philosophicus – ‘whereof one cannot speak, thereof one must be silent’. As Michael Gossop (2008) discussed in relation to what he called the ‘clinical fallacy’, if you are stuck in a specialist service seeing only those clients who never leave or who are stuck in a ‘revolving door’, perhaps you do develop a jaded view about success because you never see it. But that does not mean it is not there – just not so evident in that setting.

So is recovery all smoke and mirrors? It is not anecdotal evidence that is reported in the evidence summary by the Centre for Substance Abuse Treatment (2009) in their conclusion that 58 per cent of individuals who have a lifetime substance dependence will eventually recover. This is not ‘evidence-lite’ but a summary of the current epidemiological knowledge base – yet this is not a statistic that is widely reported, nor does it fit with a ‘recovery as fantasy’ model. The evidence would not only suggest that not everyone recovers, it would also suggest (Hser et al, 2007; Dennis et al, 2007) that there is no time that renders a person ‘safe’ from relapse. So it supports the idea that, for the majority of people, recovery is an ongoing process, rather than an event.

For both of these reasons – that recovery is a reality for many people and that relapse remains an ongoing risk for many – it is remarkable that there are eminent figures in our field who would regard the attempts to measure this and assess its correlates and predictors as a futile or pointless process.

But have we really been down this road before? Professor Drummond wearily asserts that he started with the view that long-term recovery was a viable goal, but that experience and the evidence-base taught him a level of pragmatism. This is not an uncommon perception and typically this view has two manifestations – ‘recovery is unrealistic’ and ‘this is what we have always done’.

Now the author takes the gloves off:

‘If you are stuck in a specialist service seeing only those clients who never leave or who are stuck in a ‘revolving door’, perhaps you do develop a jaded view about success because you never see it.’

Heyman (2010) cites data of the elevated recovery rates reported by airline pilots and addicted doctors, while the three meta-analyses of 12-step effectiveness (Emrick et al, 1994; Kownacki and Shadish, 1999; Tonigan, Toscova and Miller, 1996) would challenge an evidence-based pessimism around the viability of long-term recovery. Indeed, for those medical specialists who see private patients and addicted doctors, one is left to speculate about how much of the prevailing discourse is around ‘keeping the client alive and out of jail’ and about a ‘chronic relapsing condition’ and whether stable and high doses of methadone are provided as part of the ‘evidence-based care’ provided.

While platitudes about a commitment to recovery abound, the resistance characterised by the opening quotations, but by no means restricted to them, provokes questions about ownership of knowledge as power. If recovery is something that happens in the community, and is primarily self- and peer-group directed and maintained, there is little mileage in this for those who are reluctant to leave the refuge of their ‘specialist’ centre safe haven, or to discard the ‘expert’ badge conferred by their prescription pads. In other words, the failure of the treatment model has resulted in the conclusion that addiction is a ‘chronic, relapsing condition’ (O’Brien and McLellan, 1996) rather than one that is resolved outside the paradigm and power base that protects the interests of particular individuals and groups.

Isn’t this what’s at the root of much of the devotion to harm reduction and sneering at 12 step recovery. To be sure, there are other paths and those paths need to be better understood and developed, BUT practitioners working with other chronic diseases requiring sustained behavioral and lifestyle changes would LOVE to have a paradigm and community that provides the kind of holistic support for treatment goals. Why then, do so many professionals in addictions roll their eyes at the concept of recovery and the recovering community?