A Comparison of Service User and Service Provider Perspectives on Addiction Recovery

1. A Comparison of Service User and Service Provider Perspectives on Addiction Recovery Rachel Tester Helen Moriarty Maria Stubbe Department of Primary Health Care & General Practice University of Otago Wellington 6th Addiction Research Symposium April 2015 Applied Research on Communication in Health Group

2. Background Personal backgrounds • Rachel – health researcher, psychology background (non-clinical) • Helen – clinical / physician background, specialising in addictions; convenor AOD training for 4th year medical students at University of Otago Wellington • Maria – socio-linguistics background; director of ARCH Group • Research stems from earlier study “Demystifying Addiction through Personal Stories” – an online educational resource • Identified potential philosophical mismatch identified between Service User (SU) & Service Provider (SP) perspectives on addiction recovery • Co-production of knowledge Funding • “Demystifying Addiction” resource funded by Ako Aotearoa • Understanding SP perspectives funded by University Otago Research Grant

3. Aims & Methods • To explore a hypothesised gap between SU & SP perspectives on addiction recovery • To characterise any cognitive dissonance in their respective understandings of “recovery” • Method: • Healthcare SPs semi-purposely selected for interviews and focus group • Data compared with interview data from earlier study • n = 18 • Methodology: • Qualitative framework looking at a range of perspectives • Not about making representative generalisations • Framework and thematic analysis

4. The Recovery Literature • Key readings across multiple disciplines – medicine, psychiatry, psychology, mental health & addiction studies, sociology • The word “recovery” used widely throughout health care to mean: • remission from symptoms • improved function • satisfying quality of life • Mental health: “living well in the presence or absence of one’s mental illness” • International nuances – US evangelical; emphasis on individual rather than social, economic and political processes; mono-cultural; dominance of biomedical model; not reflecting values of user / survivor movement • NZ – strong emphasis on SU led recovery; importance of hope, choice and personal and social responsibility

5. The Recovery Literature - Addiction • Historical connotations with abstinent based philosophy of 12 step programs • No one universally accepted definition of recovery • 2005: Substance Abuse & Mental Health Services Administration (SAMHSA) • “Recovery from alcohol and drug problems is a process of change through which an individual achieves abstinence and improved health, wellness and quality of life.” • 2007: Betty Ford Institute Consensus Panel • “Recovery from substance dependence is a voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship.” • At the heart of recovery is a set of values about a person’s right to build a meaningful life for themselves…

6. Framework Analysis: SP Interviews Question Zone 1: Personal Philosophy • What does it mean to be “in recovery, achieve recovery and remain in recovery”? Question Zone 2: Service Philosophy • Does your personal philosophy vary from that of your service? If so, in what ways? Question Zone 3: Recovery Orientation • Do you consider your service to be recovery oriented? Can you give examples? • Can you identify any barriers that might prevent recovery orientation? Question Zone 4: Mental Health • In what ways does recovery from addiction vary from recovery from mental health problems?

7. What does “Recovery” mean? • Variously described as a personal journey of discovery and growth towards a self-defined quality of life • Both SU and SP perspectives sometimes observable within the same person • System’s level definition required for common understanding SU: “Recovery is whatever a person defines it for themselves to be. Because you know, we’re in recovery from so many different things.” (SU07) SP: “Certainly every consumer has their own idea of what recovery means. So it's kind of become a bit meaningless. It's whatever that person, what it means to them.” (SP09) General agreement that it would be a mistake for services to define recovery in terms of abstinence, and that a wider meaning was needed that could encapsulate the individual nature of recovery.

8. Measuring Addiction Te Rau Hinengaro: the New Zealand Mental Health Survey (2006): • Mental “disorders” are common in New Zealand: • 47% of the population are predicted to meet criteria for a disorder at some time in their lives • 40% have already done so • 21% have had a disorder in the past 12 months • Survey included lifetime prevalence / past 12 months for: • anxiety disorders (25% / 15%) • mood disorders (20% / 8%) • substance use disorders (12% / 3.5%) • eating disorders (1.7% / 0.5%) • Approx. 20% adult population smoke tobacco (2012/13 NZ Health Survey) • 31% adult population are obese; further 34% are overweight (2012/13 NZ Health Survey)

9. Measuring Recovery… Recovery from What? SU perspective: trauma, stress, grief, dislocation etc. and [associated ] addiction problems “I could never work out whether the problems in my life were to do with depression, or the sexual abuse, or alcohol. Because it seemed to me the depression and the problems related with the abuse were so much more prominent. You know, that's the stuff which was real to me, not the alcohol… but they'd come together…and actually I had to take charge of both, really.” (SU04) SP Perspective: addiction & mental health disorders “I think it's easier to take a nihilistic view of addiction, and you know, people relapse…I tend to view it as a as a chronic relapsing disorder, so I have a kind of a medical view in that regard.” (SP01)

10. Other key areas of tension in the data… 1. The medicalisation of addiction SP: “I've struggled being in the medical model sometimes, around labels and diagnosis. I mean the medical model, you know, look at the DSM-IV: doesn't take an account of age, gender, ethnicity and culture, which makes up the person, you know what I mean? I'd rather talk about symptoms than…diagnosis. And I think that we get it wrong.” (SP11) 2. Short term treatment vs long term recovery Short term reportable outcomes do not reflect “the bigger picture” of individual progress within a long term recovery paradigm. Concern expressed regarding the lack of support between episodes of treatment – troubled boundaries around transitioning.

11. Other key areas of tension in the data… 3. The perpetuation of stigma within services

12. Other key areas of tension in the data… 4. Fragmentation of mental health services SU: “You’re always being shuffled between departments…You felt like you’re a problem really, that’s how you felt, and I mean, I wasa problem (laughs) really for the medical people you know. It was kind of like I didn’t fit in any box really” (SU05) SP: “I think looking at the local service here, it's been great in theory, bringing mental health and addictions, but it hasn't worked in practice, partly because you've got two big teams. How do you integrate those? They try to have integrated [management] meetings, which are just... doesn't work. And everybody ends up resenting the others.” (SP10)

13. Areas of agreement • Recovery should be defined by SU not SP • Recovery should be driven by SU • Mistake to define recovery at system’s level in terms of abstinence • Considered psychological approach to addiction required – too much emphasis on biomedical solutions • Wider access to treatment services for psychological trauma needed • More preventative work needed • More time / resources needed to develop and maintain a therapeutic relationship to support long term recovery

14. Discussion • SPs should encourage SUs to think about what exactly they are seeking to recover from • The term “recovery” should be used in the clinical context to refer specifically to SU defined recovery. More accurate to use terms like “clinical treatment” and “treatment outcomes” rather than “clinical recovery” • Skew towards medical framework limits understanding of social, cultural, historical, political and economic drivers of addiction • Perpetuation of stigma within services – more education needed (including administrators & support staff) to challenge underlying assumptions about addiction and “us and them” thinking • Close attention required to identify and remove stigmatising language • Barriers to recovery still exist in service integration • Access to range of treatment options required including alternatives to traditional services

15. Implications / going forward Implications for practice or policy: • Clinical goals and management plans should be based on SU’s recovery goals • Progress towards recovery goals should be reviewed throughout an episode of care (they are likely to change) • Reportable outcome measures should better reflect SU recovery goals Implications for translational research: • Findings will be used to inform teaching, resource development, professional development and service review What’s next: • Further development of Demystifying Addiction resource, including SU produced manual for SPs on what helps and doesn’t help in recovery

16. Thank you for listening 2015 Service User Academia Symposium For anyone with an interest in mental health research or teaching, this is the most inspirational, illuminating and enriching conference you can attend…SAVE THE DATE:30th November/1st December 2015AucklandAny questions or comments?