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Stephen (Bamber) and I were speaking today at the West Midland’s Recovery Event. I thought it was a great event.
But, once again I found myself thinking and talking about how we match the social offers we make, such as housing, commensurate with someone’s progress in recovery.
For example, we can pretty much guarantee high quality housing accommodation for people who are in demonstrable total abstinence based (often 12 step) recovery.
But, we struggle to do the same for the many people who are still on a MMT script. At some point, I (we) need to try and articulate this social reality. That is, how do we match recovery and housing?
Easy to understand your blog Mark except the word commensurate, but i’ll look that up, only heard good things about you from others i hope our paths cross one day as it would be good to chat
Tony,
Commensurate means that the housing offers you get will be in line with the progress you are making in recovery. For example, if you can show me that you are x months/years clean and sober and working a ckear recovery programme then if I were a landlord I would probably be quite happy for you to occupy one of my better properties. On the other hand, if you were on benefits on a methadone programme but regularly using crack cocaine and boozing when you cashed your welfare benefits then you wouldnt get one of the better properties, in fact you would probably get a place in a hostel. One of the problems we have is that in the past we have put active addicts and drinking alcoholics in “decent properties” only for the boiler to be sold for crack etc. When this happens that landlord says: “dont send me any more of them!” I’m sure one of the RIOT gys or someone at BAC can explain this better than me because they do this all the time.
A kind of graded approach to housing makes sense, but it’s full of challenges and pitfalls. If the environment is important for recovery to happen then you could argue that the folk with the most chaotic drug use and problem severity, are the ones who are most in need of housing not associated with using and drinking. But, it’s not that simple.
I agree with you, if I were a private landlord, then absolutely I’d be looking for evidence of stability and for connections to the recovery community. Those who’ve stuck with treatment all the way through and who are now engaged with aftercare and other supports would seem the best bet.
For more chaotic clients, we maybe need to introduce a recovery orientation into hostels too. What if NA and CA meetings took place in every hostel in cities and towns? I know that happens in at least one hostel in Edinburgh.
In our service, with our partners, City of Edinburgh Council, we try to match clients with the right sort of housing, working with supported housing suppliers to find solutions for those who need more support. Others are assessed for their own tenancy and supported there by our partners.
We’re working towards setting up a ‘recovery house’ in the city along the lines of the American Model and if it is successful, we’ll try to develop this further. These ‘sober housing’ initiatives have been strongly associated with good outcomes, but have yet to develop in a widespread way here.
Integrating treatment, housing, education and training, employment, mutual aid and ongoing recovery support has got to be the way forward for us across the UK.
David, you are right it is full of challenges and pitfalls. I know that in Blackpool some NA members do service by keeping an eye on people who are trying to stay clean and sober whilst living in hostels (which as you know are some of the most chaotic places in any town). Recovery Houses and/or Oxford Houses are a great leap forward and Oxford Houses have a literature (Rowdy or Tim Leighton may know more). We also have the great tradition of City Roads as well. I believe there is a DAAT area down south (Brighton?) that has graded accommodation from 1) wet house to 2) stable on meds to 3) abstinent. There is probably a lot of good practice out there and I know that Martin Nugent did a lot of work on this (he did give me a reference for a report that was done in Bristol but I cant lay my hands on it just now). Integrating treatment, housing, education and training, employment, mutual aid and ongoing recovery support is indeed the way forward for us across the UK. A LEAP, Park View, TTP ADAS/ACORN, Providence, BAC O’Connor in every DAAT area – imagine that!
It’s also a contingency management approach. Very topical and likely to act as a powerful incentive. (Though not enough on its own).
It may interest people to know that Barnsley DAAT together with Supporting People fund a T4 project in which service users are supported in purpose built housing [core and cluster] as part of the treatment system. Onward progression is part of this project.If anyone wants some more details, please get in touch.
Just to point to some of the evidence regarding two of the possible approaches mentioned by Mark and Androcles.
1. Oxford Houses.
Yes a convincing record and great idea so far as I can see. For more read:
http://findings.org.uk/count/downloads/download.php?file=Oxford.nug
2. Contingency management.
Not so convincing despite NICE, and there are ethical implications of denying housing and meaningful occupation (as some US studies do) to people based on drug tests. Still, can’t dismiss.
For more see:
http://findings.org.uk/count/downloads/download.php?file=Milby_JB_6.txt
A quote from the commentary:
“The combined implication of these studies is that among these poor, unemployed, and largely black populations enmeshed in illegal drug use, work and housing incentives can help initiate and extend drug-free periods, but intensive support is needed to maximise and maintain the benefits once incentives are withdrawn. Without this, the gains from making housing and work dependent on abstinence rapidly erode, and it is unclear whether the long-term benefits justify disrupting the housing and employment stability of patients subject to the contingencies. This disruption is consequent on requiring abstinence in a population for whom this is a very high hurdle.”
Mike Ashton
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http://findings.org.uk
Thanks Mark for coming to talk at the event-as entertaining and thought provoking as ever. I thought some of the comments about housing and recovery had a bit of an “emperor’s new clothes” feel and have triggered more questions in my mind since then. What is the difference in “recovery” and “re-integration”? Is there a danger that the recovery agenda becomes a re-integration agenda—I got this impression in the two workshops on the day. Obviously housing and employment can be vital for some people to get into a place where their recovery can begin-but not every one. Is there the danger that a flat and a place on a training course become the latest “technological fix”, after a prescription and psycho-social interventions-but the actual addiction is never addressed? There is a fine line between treatment services advocating for social justice for clients and colluding with “victim mentality”—I’m not sure where the line needs to be but it’s probably not where I thought it should be a few years ago. Also the concept of “social offer” is very different from “rights”—anjd maybe a lot more useful and realistic. Anyway-i feel like I’m rambling and need to think some of this through a bit more. I’ll post a link to the presentations from the day once they have gone up on the website—and thanks to NTA West Mids for supporting the conference
tony
Interesting point Tony. Maybe this passage from a document I wrote a while back (at: http://www.fead.org.uk/docs/R_to_R-1.pdf) when the UKDPC were still deciding on their recovery definition is worth feeding in to your thinking (and maybe not!).
“For the politicians and public servants, who like tidily interlocking pieces from which to construct their policies, another benefit of the UKDPC’s definition is its compatibility with the drug strategy’s welfare-to-work agenda.
Since it is the government above all which defines the “rights, roles and responsibilities” of society, such a definition would give it the whip hand in deciding what counts as successful treatment and whether patients are recovered, a privilege gifted it by the treatment field if the consensus takes hold. What our ministers will mean by that phrase is back to work and no longer burdening the state, including its health services.
The process could pave the way for building the state’s welfare-to-work agenda in to the therapeutic objectives of every treatment service which aims to facilitate ‘recovery’. If the pieces fall in to place, services will have to see employment and allied social outcomes, not as a means of achieving recovery, or a fortunate product of having done so, but as the essence of recovery itself, and remaining on benefits as a sign that recovery has yet to be attained.
Take a pause and shift ground slightly to tobacco or alcohol. Would we say someone who has sustainably stopped or controlled their smoking or drinking, but still hasn’t found a job and is still on benefits, maybe even still offending, has failed to recover from their addiction? Probably not, yet this is what we plan to say when the ground shifts back to illegal drugs.”
Mike Ashton
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http://findings.org.uk
Thanks Mike-a lot more to think about! I’ve printed off the paper to read on the train tonight
tony
You make a very interesting point here, Mike. To what extent are we concerned only about the ‘problems’ associated with drug use, rather than with the drug use itself? The former view tends to go hand in hand with ideas of maintenance and stabilisation (anything which reduces the related problems like crime etc), whilst the latter fits better with abstinence-oriented approaches.
I’m not a great fan of the UKDPC definition, it smacks of a committee at work, (sorry Mike, I do value what you do) but I do think that recovery is so much more than the absence of drink or drugs.
I think the description of a journey suits recovery best. Not being in work and still being on benefits in the first part of the journey may well still be ‘recovery’, but at two years in, is my recovery as on-track as it should be?
If I’m not using or drinking, but losing money down at the bookies, neglecting my parental responsibilities and being dishonest am I in recovery? I might have overcome my chemical dependency, but my behaviours are not healthy.
In Mike’s example of the drinker who has stopped drinking, but is still offending, no I dont call that recovery and if he doesn’t drink again, I’d eat my hat. Honesty is a pretty essential component of sustained recovery in my experience.
Ultimately it’s down to each of us to define what recovery means to us. We say to those at the start of their journey ‘stick with the winners’. I used to wonder: ‘who are the winners’?
For me they are the ones who have attractive qualities, like positivity, hope, energy, spirit, compassion. They take action and they help others. They walk the walk and their values are good.
All this doesn’t come at once, but if it isn’t coming at all, I’d be worried.
Been waiting to see if Tony has any further comments. Meantime, in case of confusion, I had nothing to do with the UKDPC’s definition of recovery. I was asked to join the process but thought it was misguided because no one should be defining recovery for someone else.
As you say PeaPod, “Ultimately it’s down to each of us to define what recovery means to us.” Trouble is, don’t you contradict your self by then advancing various criteria for recovery not just for what it means to you, but for people at large who might think themselves recovered, but whom you would deny that status? eg, “In Mike’s example of the drinker who has stopped drinking, but is still offending, no I dont call that recovery.”
You also come close to saying that unless you are a model citizen you are not REALLY recovered. How many us are always honest, are never irresponsible with money, sometimes rely on benefits, sometimes are not in employment, never at least somewhat neglect our children? Why should people who formerly had problems with drink or drugs have to be better than many of the rest of us before we can accept their valuing of themselves as recovered? Why erect these hurdles? Just asking.
Mike Ashton
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http://findings.org.uk
I think the issues for me here get complicated when I try to wear two hats (that of recovering person and that of professional who has to make assessments and decisions based on the evidence before me).
The first is easiest. I’m only an expert in my own recovery and it does me no favours to judge anyone else’s. If I forget that or imply otherwise I apologise.
The second is harder as I’m tasked with responsibilities in my job which require skill, compassion, boundaries and common sense, not to mention a knowledge of guidelines, protocols and ethics.
It’s this second role which I do have dilemmas with as there are rarely black and white answers. I usually make difficult decisions in consultation with others.
I can answer honestly Mike that I often fall short on my own standards, but way less so now than I did in active addiction. Stigma of addiction should not interfere with opportunities for those of us in recovery, but behaviours will influence what is on offer to all of us. Where resources are limited, judgements need to be made on what represents efficient and best value choices. (The theme of the blog)
There are several themes to what you are saying Mike and this is only one of them. I agree that valuing ourselves is important and I don’t want to erect hurdles. I don’t accept that I was putting forward that one had to be a model citizen to be in recovery; just making progress. I like recovery framed as a journey.
Hence ‘all this doesn’t come at once, but if it’s not coming at all, I’d be worried’.
Encouraging people to reach high is something I do daily in my job. Judging their shortcomings isn’t.
Thanks for the opportunity to clarify.
Good reply PeaPod – like that: “Encouraging people to reach high is something I do daily in my job. Judging their shortcomings isn’t.” And I might have added, who among us doesn’t sometimes seem to contradict ourself, vacillate, or express ambivalance, or be not quite sure?” – I certainly do and when I don’t, maybe sometimes I should. As you say, rarely are things black or white. Absolutely no need from point of view to apologise and I shouldn’t have adopted a tone which made you feel like you should.
Mike Ashton
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http://findings.org.uk
Sorry to take a while to respond. Mike-you do have a gift of being able to cram a lot of ideas into a few words so I’ve had to re-read the article a few times. I guess my own ideas on this are still evolving but a few thoughts:
While I’m a big fan of 12 step recovery I do accept that recovery doesn’t necessarily have to mean abstinence. Several friends who were (chaotic) crack users a few years ago are definitely “recovered” though still using cocaine now and again-what seems to have made a difference is regular work (formal or informal)—none of these people would ever go anywhere near a treatment service either. I think there may be a lot in David Best’s work about using careers and life cycle? A number of service users in Birmingham do feel strongly about “medication assisted” recovery-and some of this came out at the recent conference. However, I don’t think any of us could put our hand on our heart and say that support for abstinence based recovery is available to everyone in treatment who might benefit from it-this is as wrong as forcing people down this path when it’s not appropriate.
Two years ago I was so fascinated and frustrated by the harm reduction versus abstinence debate that I went to study bioethics to better understand the moral and philosophical arguments behind it all-and came across Aristotle’s “virtue ethics” in which morality is based on the idea of “eudaimonia” or “human flourishing”-for me this is exactly what recovery is about. (Aristotle also said that in order to “flourish” people need to belong to communities that support them-which in this case would be things like NA fellowships, peer support groups, recovery communities etc). Obviously people will flourish in different ways and to different extents but treatment should result in some kind of “positive change”. Interestingly I’ve been analysing our local TOP data (minus he ridiculous crime question) which is available for the first time for our treatment plans needs assessment and it is fascinating. It shows noticeable decrease in heroin, crack and cocaine use and injecting during the first 6 months of treatment and very dramatic decreases in daily use, daily injecting and sharing needles also in the first 6 months—but after the first 6 months very little then changes. I know that some people wouldn’t be alive if it wasn’t for their treatment and others are in a much better place than they would be without it but there’s no evidence of any positive change, at the treatment population level, after the first 6 months-at least according to TOP. It could be the institutional pessimism in our services or that TOP isn’t measuring all the right things-probably both.
I think your absolutely right about the mixing up of “means” and “ends” with regards to recovery, economic regeneration and employment. Growing up in Liverpool in the early 1980s it was obvious that more and more people were using heroin as the local economy was going down the pan. I think doing something useful is a good indicator of recovery but totally agree with concerns about treasury led welfare to work agenda as this undervalues voluntary work. Maybe paying tax is a good indicator too, still chewing that one over, but it is a long way down the road for some people and I do get inspired seeing local service user volunteers growing in confidence as they get involved in things.
I’ve really enjoyed reading some of your work about how addiction is socially mediated and how society’s prejudices can keep people down and prevent recovery of any definition-and totally agree. On the other hand I think this can act as a motivator for some people—in order to avoid the stigmatising and discrimination that people with addictions can suffer-they decide to “get clean” and move on rather than wait for a just and fair society. I suppose this leaves behind the people with fewer personal and social resources and reinforces the stigma etc.
The recovery as a means of saving money stuff is interesting too. We’re starting a “total place” project in Birmingham which is looking at how more recovery orientated treatment could save different services money across the city. Some of this is political expediency—saving money gets people interested—but at the same time its highlighted that mainstream services have to do their bit and has resulted in some high level political ownership of the agenda. There’s always the danger of course that treatment is “oversold” in the same way we did with the crime reduction agenda. In short-I do believe that we have to be far more aspirational than we are-but keep in mind the dangers of over-selling treatment as the answer to all of society’s ills-which could put us back where we were 10 years ago.
Congratulations on 10 years of D&A Findings too-this is really valuable and look forward to another 10 years
Tony
Lots of interesting comments there Tony, and now I’m going to be guilty of a delayed response – unusually I’ve been dragged out of my back room here in Tottenham (see it in DDN) to actually speak to other people – today will be at the Recovery Group UK meeting in London. Over the weekend will respond.
Thanks for the congratulations on D&A Findings – it was bootstrapped up from nothing and still the laces (just about) hold it up.
Mike Ashton
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http://findings.org.uk
