The Great Debate?
Friday/18/Apr 2008 Filed in: Info - Commentary
I've just taken part in the Drugscope and Conference Consortium Great Debate looking at the issues around the resurgence of the abstinence vs maintenance arguments.
You can download Mike Ashton's article, 'The new abstentionists', here.
A number of people have asked for a copy of my speech, so I’m blogging it for them and anyone else who's interested.
Comments below or email me using the "get in touch" link on my homepage
“We are a troubled nation. It is clear where we have come from, but we have little idea where we are going. In both senses of the phrase - we do not know what to make of ourselves. As we cast about for an identity and a purpose our self image oscillates between extremes. In the space of a single decade we have gone from dizzy triumphalism to near despair …. There is something disturbing about these swings of mood. If Britain were a person, she would be a suitable case for treatment ….”
When I read that this weekend, it struck me quite forcefully how well Waldens description of a country in crisis over education – a country he said at the time of his resignation that was incapable of moving between outdated factional positions in order to improve the life of ‘even one child’ – fitted the drugs field.
I have to confess, I have no little trouble fathoming how on earth we have ended up here, once again engaged in the obsessive navel gazing that is the debate about whether the focus of treatment should be abstinence or maintenance?
Its just not a question that I can identify with, because people experiencing drug treatment need the opportunity to choose the interventions that work best for them. This might change through someone’s drug using career, with needle exchange, drop in, prescribing, inpatient and community detox and residential or community rehabilitation services coming into play at different points for different people. Sometimes, as we know, people will not move through these interventions in any convenient linear mapable way, but may well drift in and out of treatment over a protracted period of time
Of course as long as they stay for at least 13 weeks we’re all absolutely cool about it.
So is the aim abstinence? Yes. Is it maintenance? Yes. Do we need Harm Reduction? Yes. Is prevention important? Yes.
There is no right or wrong answer and really there should be no debate about this. There is no “one size fits all” solution to the problems people who use drug face. I have as little time for people who say everyone needs a script as I do for those who say everyone needs to go to a fellowship group.
People in need have a right to treatment and that treatment is going to be most effective – for all of us - when the individual has the option – working with their worker or an advocate or partner – to identify the treatment options that will help them meet their goals.
There is a world of difference between identifying appropriate interventions for an individual and defining the optimum outcome of investment in the drug strategy.While the first is indisputably the business of the individual, the other is a legitimate concern of government and the public. Of course we must be accountable for the money we spend – the quality of what we deliver must be good and it needs to satisfy the desire of government to reduce the harm related to drugs. But we must be careful about how far into the individual treatment experience this need for accountability is driven.
You see, this is where I think we have a problem. There seems to be some confusion in the minds of the great and the good about the difference between monitoring political investment and monitoring individual treatment interventions. I think that is why as a field we keep ending up in this cul de sac.
The investment we’ve been paying our rent of the back of for the past few years has been predicated on the ability of senior people in the field to ‘sell’ the concept of drug treatment to the public. This has largely been done on the basis of fear. Firstly fear of disease and secondly fear of crime. Both of these approaches have one thing in common – and that is, that they are based on the assumption that the public will not accept that people who have problems with drug use deserve treatment because they are human beings and have a right to help and support. They also both clearly identify the beneficiary of drug treatment is not the drug user. It is the rest of society, so the users voice, to the politicians and the government matters only insofar as it can be silenced. So we end up constantly chasing our tails trying to prove, beyond a shadow of a doubt that this money is being well spent.
The culture of performance management – so much a positive feature of many parts of public service over the past ten years – has become a crude dehumanizing determinism in the drugs strategy.
And this determinism is currently being expressed through a desire to mandate and control everything – from the number of pencils on the DAT co-ordinator’s desk, to individual treatment interventions. And it is this desire to control and mandate that is leading to us making a political meal of those decisions that are best left to a patient and their clinician or advocate.
So is it true that the public, with competing demands on their purse and as ever the Thatcherite legacy of measuring government efficiency on the basis of a reducing tax burden, will not accept the provision of drug treatment simply because people need help?
I don’t know.
My own experience suggests that actually while some pretty extreme views grace the pages of certain of our newspapers, whenever I’ve taken the time to talk honestly and openly with members of the public about drugs and drug users, they have been both more understanding and less condemnatory than the media might lead us to believe. It seems to me that we constantly underestimate the public’s ability to respond to human reasoned argument.
Of course the general public do not currently on the whole understand that maintenance is a positive intervention and of course they think the ideal is getting people off drugs and away from addiction altogether. That’s because largely we don’t ever bother explaining it. We have become so concerned to convince people to invest on the basis of fear, we seem to have forgotten how to ask them to invest on the basis of compassion.
So this for me is the great challenge ahead for the drugs field. It is not to reach some random conclusion according to the whims of the media or the politicians about whether our job is to make people abstinent or keep them maintained. It is to create a treatment system - through greater public and media understanding, through education and advocacy, and yes, through lobbying and campaigning – that has at its core an acceptance of the right of people experiencing problems with drug use to treatment that is not dependent on our ability to excite fear and suspicion.
So how can we do this? Well the first step is probably to be honest about what we can and can’t achieve.
Did you hear about the two guys from New Zealand who sold a brand new breed of dog in Japan? This dog they said – well its only a pup now – is the rarest most amazing and most desirable and fashionable dog you could ever have. Look at the quality of its coat! Look at the brown beguiling eyes. Imagine how beautiful this puppy will be when it grows up!
And they sold hundreds. At £800 a shot. And the people who bought them were really pleased. Until they grew up. And ate their carpets. And turned out to be sheep.
Well, I think we’ve been selling a bit of a pup – some of the claims we’ve made for drug treatment simply don’t seem to be entirely straight. Drug treatment – whether its focused on abstinence or maintenance - in and of itself is not going to solve the underlying problems that can make drug use problematic. Poverty - as my old friend Ian Smith used to say – is not soluble in methadone hydrochloride. Nor is a decrepit education system or a lack of challenging and satisfying employment or a shortage of decent housing.
But drug treatment can bring stability into someones life – the kind of stability that makes education and employment and getting out of poverty a more realistic ambition. Drug treatment can bring choice and agency back into someone’s life and drug treatment can stop people dying. And those are outcomes that we are surely able to convince the public are worth investing in - on the basis of compassion.
When the media critique our work, label our client group, or denigrate our professional judgement what should we do? Should we skulk away in a corner and wait for the Home Office to tell the public that they’d better put up with it or they’ll have a crime wave on their hands? Should we look for ever more rigid ways to determine success that depend upon ever greater degrees of coercion and compulsion? Because believe me, a treatment system that removes choice in favour of doctrinal direction will come to rely more and more on ever greater coercion. Should we turn and attack each other according to our own particular doctrine or belief system?
I don’t think so.
We need to stop arguing amongst ourselves about whether maintenance is better than abstinence or harm reduction is better than prevention, and bring our ample communication skills to bear on addressing the outside world.
We need to challenge our own tendency to factionalise and fragment. We must stop being so defensive that every challenge to the drug treatment system causes us to turn in on ourselves and argue.
We need to work with the media – not just sending in letters of complaint - to get more reasonable and realistic portrayals of drug users, drug treatment and drugs work in the press and on TV.
We also need to spend some time listening to the fears people have about drug use and the misapprehensions – many of which have been spread by politicians and the press, but some of which have been promulgated by us .
We need to work with communities to develop solutions that reassure them without consigning our clients to a treatment system so fixated on compliance with one or other doctrine that it has forgotten that the individual is the centre, the focus, the agent of change - not simply a passive recipient.
We also need to stop relying on the government to make the case for what we do and in partnership with those who directly experience treatment, start making the case ourselves for treatment to be provided according to need, where and when and how its needed. Because its our right in this country to get healthcare. Because people deserve support. Because we are a civilised nation.
And because we are a civilised nation, we must stop trying to collude with the meanest of emotions and begin to challenge the punitive, vindictive culture that is inspired by the tabloid thirst for drug pornography and the politicians hunger for votes. The same hunger and thirst that drives us to argue endlessly about which is the best approach to satisfying our political masters.
Acceptance of the right of individuals to treatment by the public is not something that’s going to happen overnight. But it is the natural next step for the drugs field and it is not impossible. Think how 70 years ago single mothers were locked up in asylums, homosexuals were imprisoned. How 20 years ago people with learning disabilities were hospitalized. Most pertinently, think how until really recently people with mental health problems were kept apart from the rest of the population – a despised and mistrusted minority – but have fought back and changed public attitudes. There are things we can do to drive change. There is a different way forward than this constant reinforcing of our own specialism.
One of them, as I said, is to stop arguing among ourselves and to accept that different things work for different people.
And actually, you know, I think we do, by and large accept that. I just think we’re frightened to admit it. Frightened because having created the behemoth of the feral drug user, we’re scared to say to the media and the public that we haven’t really got a simple solution. That the best we can do is hope that we can keep people as safe as possible and help them make choices that are less damaging and less problematic than the ones they might make without us.
In the consultation I did last year with Drugscope we talked to 100s of people across the country about what the future of drug treatment and strategy might hold. One of the questions that kept coming up was “what is treatment”.
It reminded me of the story my friend from Brussels told me about what happened when a French cultural group and an English cultural group got together and decided they would run a dance festival to celebrate the friendship of our two nations. They raised the finance, they set up the committee, they got the support and the venues …. And then it all stalled.
Why? Well they couldn’t agree what dance was.
Well, I think we do know what treatment is. I think anyone who’s been involved in effective treatment – as a punter or as a worker – knows exactly what it is. It’s a good relationship, a proper dialogue between client and worker, the trust, time and opportunity to access whatever it is our clients need to keep them safe, keep them alive and help them choose to move on. Whether that's abstinence or maintenance.
Its probably time we stopped getting so screwed up about our traditional rivalries. We need to defend what we do not by looking inwards at debates like this, but by opening an honest dialogue with the rest of society and beginning to say out loud the things we all know -
People are different. Good drug treatment responds to that difference, offers choices, is not rigid or doctrinaire but works flexibly with the individual.
That’s how drug treatment changes peoples lives. And that’s what we do.
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