This article was published in Druglink, September/October 2011
As the organising principle for drug treatment, harm reduction was not rocket science. Provide needles and syringes to make contact with injection drug users and reduce the transmission of blood borne viruses. Provide maintenance medication to maintain that contact and cut crime. We did this and it worked. However by 2005 there was growing concern that this was not enough, articulated in the NTA‟s Treatment Effectiveness Strategy. Questions began to be asked about whether recovery should be the organising principle for treatment.
In that year, a group of almost twenty commissioners, providers and ex-users met in Manchester to face this challenge from a local perspective. The North West was where the UK heroin epidemic started and we had a disproportionately high drug-misusing population. We discussed the role of abstinence- based treatment and how to move from a focus on quantity to an emphasis on quality. This group gave birth to the North West Recovery Forum, which has been exploring the ways that treatment can be organised to support recovery ever since.
Recovery is now the organising principle of everything we do in the commissioning and provision of substance use disorder treatment. Building recovery in communities is one of the triple pillars of the coalition government‟s Drug Strategy, with its commitment to create a recovery system that focuses not just on getting people into treatment but getting them into full recovery and off drugs and alcohol for good. We have our own UK recovery champions but who inspired and inspires them?
When harm reduction was the organising principle we often looked to Europe and Holland in particular, for inspiration and ideas. With recovery as the organising principle we look to the US and draw inspiration and ideas from four of their most influential recovery thinkers and writers. These are Dwayne Simpson, George De Leon, William L. White and John McKnight. Together they also represent a range of interventions that move from the individual to the collective. The treatment of addiction and „addiction science‟ has focused primarily on the individual. „Recovery‟ on the other hand is focused on fellowship, mutual aid, community and the collective.
Dwayne Simpson (1) first came to the NTA‟s attention in 2005 as a result of the NTA partnership with the Institute of Behavioural Research (IBR) at Texas Christian University (TCU). At that time the NTA were very keen to look at ways of reducing the numbers of individuals who dropped out of treatment very early. Dwayne Simpson is internationally recognised for his work on maximising treatment engagement and retention. But, it was Dwayne‟s emphasis on treatment as a journey that grabbed the attention of the North West Recovery Forum. People on journeys need maps and the International Treatment Effectiveness Project (ITEP) is perhaps most associated with mapping. This was revolutionary to our client group. At a meeting of the North West service user group in 2005 the idea of treatment as a journey was met with a mixture of quizzical and concerned responses. “What do you mean treatment journey? I didn’t know I was going anywhere? I thought I had arrived. I am settled on methadone maintenance. I thought this was it!”
This was met with: “You’re on a train that has MMT (Methadone Maintenance Treatment) on the side and unless you get off then the evidence based destination is the grave”.
Also in 2005 one of Dwayne‟s colleagues was visiting the UK and visited a classic Tier 3 community prescribing centre. They came back to the NTA and said how impressed they were with the “dosing clinic” and looked forward to seeing treatment. They were a little shocked when they were told “that is the treatment”. So, Dwayne Simpson gave us the whole notion of recovery being about movement, journeys and maps. He also prompted us to question whether medication dosing alone should be classed as „treatment‟.
George De Leon is perhaps best known for his work on Therapeutic Communities (2) and the stages of recovery (3). But it was in the work of George De Leon that we first came across the notion of Recovery Oriented Integrated Systems (ROIS). We set ourselves the challenge of trying to articulate or better still, establish a ROIS in a geographically defined community. De Leon‟s work on community as method was crucial in our thinking. De Leon‟s proposition is that by coming together as part of a therapeutic community people can learn how to live right. “Right living” is another of De Leon‟s contributions to the UK recovery
movement. In the past, places like Liverpool had sent significant numbers of people to residential rehabilitation centres far away. Northern regional accents could be heard in residential rehabilitation centres all over the South of England. If they did well they stayed away from their home towns and cities. If they didn‟t do so well, they relapsed and came home. So, North West commissioners of residential rehabilitation were exporting „success‟ and importing „failure‟. Inspired by the work of George De Leon we wanted to see if we could establish a ROIS in Liverpool. Can people get well where they got sick? Can people learn how to live right in the same communities where they had been living wrong? When George De Leon came to Liverpool in March 2011 this question had been answered with a resounding yes.
Liverpool now has a very large and growing network of Narcotics Anonymous (NA). Cocaine Anonymous (CA) and Alcoholics Anonymous (AA) have seen similar growth.
Inspired by the work of George De Leon we have embraced the mutual aid mantras of “I can’t but we can” and “You alone can do it but you can’t do it alone”. Most people start using substances as a communal thing. There was a time when substance use was a fun thing to do with friends and peers. In the grips of active addiction social isolation takes hold, self will runs riot and the addict‟s identity as a victim takes hold: “Poor me, poor me, pour me a drink”. Long term sustainable recovery for George De Leon requires a complete identity change. With this identity change people become pro-social, conventional adult citizens. If their recovery is visible and attractive it becomes contagious. They become role models for recovery. They show that recovery is a reality. They model recovery in their communities and living in those communities becomes a method of recovery.
This is where the work of William L White became crucial (4). William L White is one of the most important thinkers and writers on recovery and recovery communities. At a seminar in London in March 2009, William White employed the metaphor of a dying tree. You can take a tree that is dying and dig it up and replant it in rich soil. If you nurture the tree it can flourish. But, if you dig it up again and replant it in the old soil it will start to die again. The question then becomes, can we enrich the soil so that the tree can survive and thrive without having to be dug up and replanted elsewhere. In recovery terms; can you get well where you got sick? The answer from Liverpool is yes you can or more precisely yes we can. The recovery community becomes a method of recovery. William Whites latest contribution is Medication Assisted Recovery and Recovery Oriented Methadone Maintenance. This work reminds us that there are many paths to recovery; all are a cause for celebration and that includes people on methadone and Buprenorphine. The best treatment will prepare you for ongoing support in a community. Commissioned treatment systems can support but not provide long term recovery. Long term recovery is sustained and maintained in fellowship and mutual aid in recovery communities.
By 2009, it was becoming clear that there was a piece of our recovery jigsaw missing. What happens to people in long term recovery? Do they just stay in 12 Step and SMART Recovery meetings? Where else do they go and what do they do? We had come to believe that people in long term recovery were “better than well”. This is where the work of John McKnight and his colleagues fits into the UK recovery picture. Asset-Based Community Development (ABCD) has emerged as a way of responding to the challenges posed by general health and social inequalities (5). The most difficult and complex cases of addiction, presenting to public services for treatment, tend to be emerge from, and are located in, the most impoverished communities. Treatment alone cannot provide a long term answer to addiction that has its roots in intergenerational health inequalities.
As the treatment system prepares for the transition to a new public health system, under the auspices of a new body to be called Public Health England, the NTA is already encouraging local areas to adopt asset based interventions. Its action plan for 2011-12 makes clear this approach will enable partnerships to assess the recovery networks of their own communities as part of the local strategic planning process. Treatment that is recovery-oriented and recovery that is asset- based can ensure that our sector plays a major role in our new public health system. People recovering from addiction in the same post codes that they were sick are real community assets. They show that new and healthier identities can be forged by coming together and creating communities that foster recovery in the widest sense of the word.
(2) De Leon, G. (2000). The therapeutic community: Theory, model and method. New York: Springer Publishers, Inc.
(3) De Leon, G. (2005) Stages of Recovery Univ. of California at San Diego (UCSD) Center for Criminality and Addiction Research Training and Application (CCARTA)