Therapeutic nihilism
“None of them will ever get better”, the addiction doctor said to me of her patients, “As soon as you accept that, this job gets easier.”
This caution was given to me in a packed MAT (medication assisted treatment) clinic during my visit to a different city from the one I work in now. This was many years ago and I was attempting to get an understanding of how their services worked. I don’t know exactly what was going on for that doctor, but it wasn’t good. (I surmise burnout, systemic issues, lack of resources and little experience of seeing recovery happen).
Admittedly, a part of me recognised an echo of the sentiment. I’d worked for many years in inner-city general practice and back then, to be honest, I did not hold out as much hope as I might have for my patients who had serious substance-use disorders. After all, the evidence in front of my eyes suggested intractable problems. All of that changed when I began to connect with people in recovery and started to understand the factors that promote it.
Palliation or something better?
I don’t think my colleague’s perspective was (or is now) the predominant view, but by no means is it unique either. An addiction specialist has fairly recently urged us to accept that some ‘do not have the luxury of recovery’, seeing it as ‘a convenient concept, but an unobtainable reality for many people who use drugs’, who are really in ‘palliative care’. I struggle with this perspective. Some would say it’s realistic. I think it’s pessimistic.
Of course, there are people whose chances of resolving their problems and going on to achieve their goals remain low despite support, but who gets to choose who gets ‘palliation’ and who gets something better? We don’t start out with palliation as a goal of cancer treatment; why should addiction treatment be any different? If our treatment offer is focussed on palliation and only the few – the worthy and fortunate – get to go further, we are letting people down badly. Professor David Best has pointed out that this sort of therapeutic pessimism is a major barrier to the effective implementation of a recovery model.
My assessment in my visit to that MAT clinic was that I could not work in a service where views like that, for whatever reason, had become acceptable and explicit. However, rather than be defeated, I found instead that this provoked an energy within me to try to make a difference. That one incident, perhaps more than anything else (save my own experience of treatment and recovery), drove me to set up the service I now work in.
The clinical fallacy
While therapeutic pessimism undoubtedly exists, I am buoyed up by my past experience of working in teams in community settings where expectation of what is possible is much higher. I can think of many colleagues who set the bar high every day in their work, even when they are working in demanding circumstances.
While despairing and cynical views are not the norm, it is apparent though, for whatever reason, that some working in the field don’t hold out as much hope as they might. I’ve heard enough reports from individuals who feel they were discouraged or blocked from moving on towards their goals to know that it happens too often.
This nihilistic view of the potential of individuals to resolve their problems and move towards their goals can be explained to some degree by something Michael Gossop called ‘the clinical fallacy’. This is the situation in which the clinician sees all of the challenging presentations and relapses, while the people who resolve their problems move out of treatment and are not seen again.
The clinician is confronted continually by their failures and denied the benefit of seeing their successes.
Michael Gossop, 2007
This may explain findings from elsewhere which show that we professionals working with people who have substance use disorders consistently underestimate what our clients/patients are capable of. This is important. The clients of clinicians who are more positive do better[1] and conversely negative or ambivalent attitudes in professionals are linked to higher risk of relapse.
Professor Best, interviewed by William White in 2012, referred to work he’d done in the UK, scoping out the aspirations of addiction workers for their clients. He had asked them to estimate what percentage of the people; they were working with would eventually recover. The average answer was 7%. Evidence actually suggests that over time most individuals are likely to recover. However, if I believe your chances of recovery are only 7%, then I’m instantly holding you back because of my own beliefs and behaviours – conscious and unconscious. My bar is set way too low.
An Australian study found that practitioners there were more optimistic believing that a third of people with a lifetime substance dependence would eventually recover. But this is still an underestimate.
In general, it is fair to say that SUs [service users] look for tough criteria to define ‘being better’ – perhaps tougher than their practitioners.
Thurgood and colleagues, 2014
Raising the bar
Eric Strain picked up this theme of aiming too low in a recent editorial in the journal Alcohol and Drug Dependence when he wrote:
The substance abuse field in both its research as well as treatment efforts is not giving due consideration to flourishing. We need to renew our efforts to give meaning and purpose to the lives of patients.
Eric Strain,
Saving lives and reducing harms rightly need to be our first concerns, but is there a danger that we stop right there because we see the risks of our patients or clients going further as being too high? This week I was talking to an experienced addiction psychiatrist, now retired. He told me that early in his career he gave up trying to predict who was going to do well and who was not. He’d seen people, ostensibly with little going for them, get better from what looked like intractable problems. He’d seen others with a great deal of recovery capital die from addiction, despite the best efforts of family and professionals to support them. It’s hard to make predictions perhaps, but not too hard to hold out hope for everyone.
The necessity of hope
There are actually reasons to be more optimistic anyway. As I say, long term follow-up studies and retrospective studies of people in established recovery suggest that most people can expect long term resolution of their symptoms although this can take some years and several attempts during which we need to focus on keeping things as accessible, supported, and safe as possible, underpinned at all times by hope that things can and will get better.
So what of hope? Hope can be described as an emotion, a cognitive process or a positive anticipation which helps to motivate goal-oriented behaviour. However we define it, it is essential for recovery from substance use disorder, yet it features little in textbooks, guidelines and academic studies.
The patchy availability of hope in ourselves, our services and our service users does need to be addressed. Hope is a catalyst for moving forward. Academics have found that positive expectancies, like hope, predicted higher levels of resilience against post-traumatic stress symptoms. Other researchers have identified the critical role of hope in terms of survival.
The inclusion of hope in clinical practice shows considerable promise. Individual, group, and family therapy interventions that incorporate hope theory have been found to reduce symptomology and mediate recovery from various psychological and psychosocial conditions
Gutierrez & colleagues, 2020
It is apparent that hope is a necessary ingredient, not only for patients/clients to progress, but for professionals too if we want to be effective in supporting individuals towards their aspirations. I’m not suggesting we come at this with an unrealistic Pollyanna bent. Without manageable caseloads, support from colleagues, good clinical supervision and adequate resources – including joined-up care – compassion fatigue can set in and the therapeutic relationship can suffer. Hope, though vital, can ebb away.
“We must address issues around staff burnout, which I suggest is related to repeated exposure to client relapses without parallel exposure to clients in long-term recovery.” David Best, 2012
Prof David Best
The introduction of hope
In that conversation with William White, David Best encourages us to ‘inspire belief’ through a variety of interventions::
“The interesting issue for me is much less about what particular therapies and modalities we offer and more about whether we can inspire belief that recovery is possible, establish a partnership between the client and the worker to facilitate that change, mobilise recovery supports within the client’s natural environment, and link the client to those community resources.
We also need to locate recovery within a developmental perspective that recognises the lengthy (and non-linear) journey that most people experience in recovery. This means there are plenty of opportunities for a diverse array of interventions and also that people will evolve in their needs and their resources as the recovery journey progresses.’
Lived experience and hope
Structurally, the goal must be to create recovery-oriented systems of care, but within our existing services, there is a straightforward way to infuse hope. We can do that by embracing lived experience and introducing it into what are normally professional settings. Connecting those we work with to others in recovery stimulates aspiration. It’s true that some professionals are resistant to this concept, but people with lived experience can be involved in treatment settings, acting as role models and beacons of hope to everybody’s advantage – staff and patients. They can also bridge the gap between treatment and recovery communities.
In a local evaluation of a peer support model introduced into a harm reduction service, benefits to the service users were apparent, with greater levels of engagement and a high approval rating of the intervention. What was unexpected though was the benefit to members of the staff team. Because they normally worked with people at a much earlier stage on the recovery journey, the staff were not used to seeing people who had moved on from their problems. That experience of working alongside people who self-identified as being ‘in recovery’ changed the beliefs of the team, raising expectation and hope.
In a study[2] published this month which looked at the feasibility, accessibility and acceptability of peer navigators in roles that aimed to reduce harm and promote recovery (wellbeing, quality of life and social functioning), the researchers added to the growing evidence base that peers with lived experience can positively influence not only the reduction of harm, but also improvements in quality of life through various mechanisms including role-modelling.
Many participants also described less tangible but nevertheless important changes, including increased confidence and hope.
Parkes and colleagues, 2022
This was not all plain sailing, but staff noted how the peer navigators were able to spot things that staff didn’t, had tenacity with clients and could engage more ‘chaotic’ or ‘hard to reach’ clients.
What’s lovely about this open-access study is how easily the lessons can be adopted into practice. There are issues to be tackled and more work needs to be done on capturing outcomes, but this has the opportunity for us to tackle therapeutic nihilism within ourselves and within our services.
Recovery champions can convey the possibility that things can be different and offer living proof of that difference in their own lives.
Prof David Best
Generating hope
Peers with lived experience don’t just have the potential to introduce hope. Research also suggests that peer contact can help to reduce stigma. Visible recovery is generally inspiring, though some may be threatened by it. There is mostly a contagiousness about it which generates hope. I wonder if my colleague working in that challenging MAT clinic who came to believe that nobody would ever get better would have avoided therapeutic nihilism if she were buoyed up by working daily shoulder to shoulder with those with lived experience.
When we see burnout, despair and therapeutic nihilism we need a compassionate response, but more than this, we need to transform situations where hope has atrophied. Moving to peer support models in every treatment setting is surely an effective way to generate hope, not only in those who use our services, but also in ourselves.
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[1] Simpson. D., Rowan-Szal, G., Joe, G., Best, D., Day, E., & Campbell, A. (2009). Relating counsellor attributes to client engagement in England. Journal of Substance Abuse Treatment, 36, 313–320.
[2] Parkes T, Matheson C, Carver H, Foster R, Budd J, Liddell D, Wallace J, Pauly B, Fotopoulou M, Burley A, Anderson I, Price T, Schofield J, MacLennan G. Assessing the feasibility, acceptability and accessibility of a peer-delivered intervention to reduce harm and improve the well-being of people who experience homelessness with problem substance use: the SHARPS study. Harm Reduct J. 2022 Feb 4;19(1):10.