LOTS OF HAPPY ENDINGS
Why do people not listen to stories of success when it comes to addiction, ask Dr David Best, Safeena Ghufran, Rajashree Ray and Ed Day. "Success can be measured. Our duty as researchers is to provide a voice for it."
This article appeared in July/August 2007 Addiction Today journal and is even more relevant today.
Download Addiction Today 107 – happy endings – David Best
Research is generally a tricky business… As researchers, we spend all of our time persuading people to take part in interviews, they often spend the interview looking at their watches and yawning, then we disappear into our ‘ivory towers’ — the sad reality is cramped offices in university dungeons — and, years later, we publish reports which are read by only two or three people whose general response tends to be “well that’s obvious isn’t it. I could have told you that and saved all that time and effort”.
It is even worse with drug users in treatment. We now almost always have to pay clients to take part in research studies —and we can still be met with grumpy, surly, monosyllabic responses.
So it is so refreshing to carry out research where people are enthusiastic, where we do not have to chase the sample and where our questionnaires just are not long enough to cover all of the things that participants want to say. And then these particular participants tell us that they are going to give the questionnaire to all their friends to fill in.
The End of Careers questionnaire, which we piloted on behalf of the National Treatment Agency for Substance Misuse at the 2006 UK/European Symposium on Addictive Disorders and then was included in Addiction Today, has been a great experience for us as a research team. But it has provoked for us the question of why nobody else is interested in this area of work.
Former users, particularly those who are working in the field, have been so generous with their time and their experiences that there is a river of PhDs and a mountain of research papers available for all who are interested. Yet we still talk about ‘chronic, relapsing conditions’ and live in world where maintenance is seen as the best solution to the problem of addiction.
BACKGROUND AND PROCESS
The rationale for our interest in this area is that we regularly come across treatment successes in clinics, in commissioning teams and throughout caring agencies: former alcoholics, heroin addicts and other drug users who have recovered and now work in the field, where their experiences make a vital and irreplaceable contribution to service provision. Strikingly, the academic literature does not reflect these experiences or this kind of treatment journey. Instead, our journals are full of papers of horse races between different medicines and between different talking cures, and our services aim for reduced crime and reduced health risks.
What we have done is to chart out what the experiences are of people who have had problems and who have come out the other side. It is clear that there is no going back — dependent substance users do not return to their pre-addiction states and status — but there is a going forward. In spite of the mantras about safety and reduced harms, we have attempted to chart the success stories which are not rare, which are not the exception, but characterise one group of addiction careers. Our research in this area is only starting, and this article summarises our first stumbling steps to find the right research tools to describe this process.
We piloted a short questionnaire at UKESAD 2006, then took our questionnaire to a reunion at Castle Craig Hospital, and finally Addiction Today allowed us to include the questionnaire with some big amendments in a summer issue last year. What we have included on these pages is the sample of individuals who told us they were working in the field.
WHAT DID WE FIND?
There were 187 former users currently working in the addictions field who completed our questionnaires. They occupied a wide range of positions in treatment services, such as service managers and directors, drug and alcohol workers as well as doctors, nurses and social workers. On average, they had been working in the addictions field for about seven years and the average length of time since last substance use was about 10 years. In other words, this group had typically been drug- or alcohol-free for about three years by the time they started working in the field and had worked in this area for the next seven years.
It is important to note that these are averages and each person’s story was different and the addiction careers which were described to us varied from person to person.
In terms of what the people had been using during their addiction careers, we broke the sample down into four groups on the basis of the drugs they reported at some point having used on a daily basis:
- problem drinkers only (24%)
- illicit drug users only (45%)
- illicit drug use and alcohol (16%)
- never used any substance on a daily basis (16%).
There were essentially four key questions that we wanted to answer. The first was "What were your motives when you finally managed to stop?". The first table above shows the answers which we were given, with the emphasis on being "tired of the lifestyle" and because of psychological effects. We were surprised that external pressures — family, criminal justice, work — did not appear to play a big role.
However, we knew that the successful attempt was not the first attempt for most people in our sample, with 117 people reporting an average of 4.9 previous attempts at achieving abstinence. We were interested in finding out why this particular attempt had been successful so we also asked what helped each person to stay drug-free. This is reported in the second table.
The main reasons given were about changing social networks, about support from (non-using) friends and, with some effect, of having the support of a partner. Religious or spiritual factors were also prominent. And it is striking how many people reported that stable housing and work were important factors in allowing them to remain drug-free.
We also wanted to know why previous attempts had not been successful. The most common responses given were that people either were not ready to stop or that they did not have sufficient support. Typical responses were that “I was not ready to stop; it was just pressure from the family” and that “I did not really understand the nature of my problem and I did not really want to stop”. Similarly, comments indicating the lack of support included “Because I had no guidance and felt like I was the only person who suffered with my head problems” and that “I did not know how to stop and there were no resources I could find”.
The other crucial finding was the prominence of 12-step support in the recovery journeys reported by participants in the study. Not only was lack of awareness of 12-step support often cited as a reason for previous failures, but 45 individuals provided us with comments asserting the importance of this approach.
The comment that “active participation in 12-step fellowship on a continuing basis” was representative, as was the report that the reason for successful resolution was “admitting the problem and finding a solution in a 12-step programme”. For many of the people who took part, 12-step work was at the heart of their recovery journey and was an ongoing component of success.
SO WHAT CAN WE CONCLUDE?
The findings are encouraging and, yes, they probably do say things that we already know. Recovery is an individualised process and averages can be misleading. But people can and do recover even though lasting success rarely happens the first time. There is no single magic bullet and, at least for this group of recovering addicts, what appears to have happened is a long-term psychological change coinciding with the discovery of an effective peer support network.
The findings that people become ‘tired of the lifestyle’ and that they develop insight into their problems and resolutions might be a longitudinal process which requires practical accompaniments: stability of housing and employment and a non-using peer group. Whether this must be done through 12-step work remains unclear as this group of people used AA and NA extensively.
Our challenge now is to assess what else, if anything, can work and for whom.
The bottom line for us is that success exists. It can be measured. Our duty as researchers is to provide a voice for it in the addiction research bluster of maintenance and medicine.
Dr David Best is chair of the Scottish Drug Recovery Consortium and reader in criminal justice at the University of Western Scotland. He was senior lecturer in addiction at Birmingham University's Medical School, as well as research manager for the National Treatment Agency for Substance Misuse. He has worked in the addictions field for 19 years, including at the Institute of Psychiatry/ National Addiction Centre and the Police Complaints Authority. He has completed work for the (previous) Prime Minister's Delivery Unit.