Clinicians’ attitudes to recovery

Which teachers were the best when you were at school? Likely the ones who believed in you, connected with you, who had a vision for where you could go and who enthusiastically helped you get there. I remember struggling with maths at school – I was always a writer, not an adder. Unfortunately I needed a higher level maths qualification to get to medical school.

Good teachers got me there. The same characteristics – vision, enthusiasm, affirmation, belief patience, engagement and holding out hope when there may not be much around, are likely to define the best clinicians too.

Limitations of treatment

In 2014, Pillay, Best and Lubman took a look at Australian clinicians’ attitudes to recovery in a research paper. They started by looking at the limitations of treatment

• Lack of consistency between episodes of treatment
• Focussing on a primary problem rather than addressing social, health and legal issues
• Lack of involvement of families
• Lack of referral to mutual aid

Now I have to say those themes are just as relevant today as they were six years ago. Perhaps more so.

What is ‘recovery’?

Plenty of definitions exist, but lack of agreement on what recovery actually is can be a problem. The role of abstinence is seen as contentious by some. As recovery is often seen as a process, say the authors, it is difficult to measure and may be better captured by a set of principles.

The study background

The authors explain the context to the study: research supports the idea that clinician attitudes can influence client outcomes, where clinicians who are more positive about being able to support client recovery achieve better client recovery outcomes. Conversely, ambivalent or negative clinician attitudes are associated with increased client relapse and reentry into treatment.

I remember a manager of a service saying to me a few years ago, when those with substance use disorders still had to turn up at the Benefits Agency to claim benefits, that if his clients could out out of bed and get there, that was recovery as far as he was concerned. I remember thinking ‘that’s surely a low bar’.

Clinician attitudes

The aims of this paper are fourfold:

1. What do clinicians think ‘recovery’ means?
2. What do they think are the risks and benefits of moving to a recovery-oriented approach?
3. Do service types and other variables influence attitudes?
4. Finally, what are clinicians’ expectations that their clients will eventually achieve recovery?

The study

Fifty alcohol and other drug clinicians from a variety of backgrounds completed questionnaires. Thirty-five of them also took part in structured interviews.

Definition of recovery

Just over a third said that recovery was ‘moderate controlled use of any drug and alcohol’. A further third said ‘no use of any drug or alcohol’ with the rest in between or not answering.

Risks and benefits of a recovery approach

There was much agreement of the potential benefits, with residential treatment providers being most positive. On the other hand, some said, ‘that’s what we are doing already’ (always sends up a red flag for me) and expressed concerns that if clients didn’t have recovery goals, then recovery services may seem to exclude them. The balance of harm reduction services and recovery services was also highlighted and the place of 12-step groups ‘imposing recovery’ was mentioned – whatever that means. Could it be the ‘high bar/low bar’ issue again?

Expectation of recovery

Just over half made a stab at estimating the proportion of clients they thought would eventually achieve lasting recovery. The clinicians reckoned about a third of their clients would get there. The world literature suggests it’s about half. In studies professionals consistently underestimate what their clients want and are capable of.

Study Conclusion 

The authors conclude that the term recovery is a contentious one, with many different interpretations and associated attitudes. They suggest that as services embrace change, it will be worth taking time to work with clinicians to create an atmosphere which is conducive to a Recovery Oriented System of Care. To help the process, rather than trying to pin down ‘recovery’ precisely, an ‘overarching set of principles’ will be more useful. Getting recovering people involved in the discussion will be an important catalyst.

Reflections

It’s interesting to me (but not surprising) that residential treatment providers were the most positive about a recovery approach. We get to see lives transformed through the process of recovery and, in aftercare and beyond, see recovery being sustained. That’s not always something colleagues in different parts of services see.

Getting recovery-oriented systems of care established and working well has been highlighted as important in the last drugs policy and in this one. Everything joined up from harm reduction services (drug consumption rooms for instance) to residential rehab and community recovery resources. Would be good to see these operational across Scotland.

This theme of the importance of lived experience detailed in this study (embedded in the Scottish Government’s drug policy Rights, Respect, Recovery) is welcome. The recently-appointed drugs minister, Angela Constance MSP, has just tweeted a commitment to that very thing which can only be welcomed.

Irene Pillay, David Best & Dan I. Lubman (2014) Exploring Clinician Attitudes to Addiction Recovery in Victoria, Australia, Alcoholism Treatment Quarterly, 32:4, 375-392, DOI: 10.1080/07347324.2014.949126

This is an updated version of a previously published blog.