Missing the point

The American Journal of Public Heath (behind a paywall) has a new study looking at 2 year trajectories of residents in a “wet shelter”.  The found that the residents reduced their drinking by 40%.

Reducing drinking in these cases is a very good thing.

To me, there are several important questions but the first might be, “then what?”

Do we pat ourselves on the back that they are housed and drinking less? Mission accomplished? Or, do we view this gradual change as a start and continue to move them toward recovery?

If we’re talking about the latter, I have no quarrel with a program like this, in principle. (I say, in principle, because, in the context of scarce resources, my bias will probably be that funds would be better spent on improving treatment access and services.)

The study and coverage of it makes me bristle a bit because it responds to and refutes an “enabling hypothesis” that a housing first approach will increase an alcoholic’s drinking. This seems like a bit of a straw man.

Maybe I’m an outlier among people who are concerned about these kinds of programs, but my concerns are:

  1. That this kind of program does nothing to address the individual’s alcoholism. (Not that it would make it worse.)
  2. That it’s a palliative response to a treatable condition.

The study does address #1 to an extent. My response is that drink counting doesn’t tell you a whole lot about alcoholism, particularly with very severe cases. Addiction’s impact is so multidimensional to the individual and the loss of  control extends so far beyond drinking that it’s dot as though a 10% reduction in drinking equals a 10% improvement. Several analogies come to mind, for one, if your’re in chronic and severe pain and the pain is reduced by 10%, is that success? Does it equate to a 10% improvement in well being? Not necessarily. Sometimes, small improvements in a symptom are accompanied by disappointment and depression that this might be as good at is gets. The person may still be disabled. The pain may still be severe enough to interfere with sleep, relationships, other pleasures or participating in activities that are associated with wellness.

Again, I welcome improvement, IF it’s accompanied by an effort to continue moving in the direction of recovery.

My concern about the palliate approach is that it’s based on the assumption that these people can’t get well. This assumption often rests on other assumptions:

  • That they’ve had access to treatment before and have not responded.
  • That they don’t want recovery.
  • That treatment is too expensive.

The problems with these assumptions are that:

  • They probably never got treatment of the appropriate duration and intensity.
  • Context is important in wanting recovery. Does the person see living proof that recovery is possible? Does the person work with helpers that express hope and optimism about their capacity to recover? Is help of adequate intensity and duration available on-demand?
  • Treatment and recovery support doesn’t have to be expensive.
    • Arguments based on costs and savings are arguments within the economic monoculture and deserve re-examination. (Hospice is probably much cheaper than cancer treatment too, does that make it the right thing to do?)

There’s a way in which this is two things at once. An aggressive attempt to meet the basic needs of some very vulnerable community members, AND a form of abandonment by lowing expectations and offering no hope for recovery and wellness. (There was no reference to recovery  or gradual movement in the direction of abstinence in the article.)