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Bizarrely, the major piece of Home Office research that was commissioned by the Home Office called DTORS (Drug Treatment Outcome Research Study) has been published at the end of last year with little or no comment from the field, including I think the NTA.
This was seen as a follow-up to the massively influential NTORS (National Treatment Outcome Research Study), with a modern focus on analysing the newer criminal justice treatmemngt pathways which had developed since the late 90s.
As I say, I have no idea why this has gone laregly undiscussed but the results of qualitative research look quite helpful to me.
Workers and service users from a variety of agencies were interviewed, and various conclusions were arrived at. One of them was that the recovery stage/recovery state of people coming in and out of services in terms of where they were on their recovery journey might be classified in five different ways (though they were at pains to say this wasn’t comprehensive).
These were:
1) Recovering – treatment seekers in this category were no longer using illicit drugs, or were using a minimal amount and felt it was no longer a problem. While they may have been using a prescribed drug as an aid, it was not the critical factor in their resilience to taking drugs. Any use of other illicit drugs was limited and did not impinge on other activities or relationships.
They had a broadly positive mental state and were able to think about and make realistic plans for the future. They may have had occasional lapses but these did not lead to a full-blown return to uncontrolled use. They wanted to stay off drugs and had the sense of stability to feel that was achievable. They were not committing crime, were building positive interpersonal relationships and taking positive steps in terms of education and employment.
2) Stalled – treatment seekers in this category were also no longer using a significant amount of illicit drugs, but felt unable to move forward and get on with their lives. For opiate users their prescribed drug use was a critical factor in their resilience, and in some cases they were using other illicit drugs.
Generally, they had a poor mental state, and, for example, found it hard to think about and make plans about the future. Some were committed to staying off drugs, while others were ambivalent, but in both cases there were doubts about whether it was achievable. Treatment seekers in this category tended to describe their interpersonal relationships as poor and they reported making few, if any, positive steps in terms of education and employment.
3) Substance Replaced – treatment seekers in this category were no longer using the illicit drug they entered treatment for (or had significantly reduced their use), but had replaced it with an alternative drug.
They tended to have a poor mental state, and so found it hard to think about and make plans for the future. Their interpersonal relationships were mostly described as poor and they were taking limited if any steps in terms of their education and employment needs.
4) Relapsed – treatment seekers in this category had started using a significant amount of an illicit drug again having experienced a significant period of abstinence or highly limited use.
They had a sense of failure and guilt and found it difficult to visualise the future. They had a strong desire to stop using again, but had doubts about their ability to do so. Their interpersonal relationships, along with their education and employment situation, were suffering.
5) No Change – participants in this category had experienced little change in their pattern of drug use after contact with treatment agencies. They had an unpredictable mental state, reflecting their current drug use and circumstances, and a similarly unpredictable ability to think about and make plans for the future.
They had a negative or ambivalent attitude to drug use, but felt unable or unwilling to stop their use, and in some cases they were committing crime. Their interpersonal relationships tended to be poor and they were taking limited, if any, steps in terms of education and employment.”
These people will have different needs because they are at different points/in different states. So I assume they will best be engaged by services using different kinds of strategies. A one-size fits all approach won’t so this, and I guess the challenge for services is to be sufficiently canny to be able to gauage this correctly and respond appropriately.
Does this typology help us in any way?
Hi Simon – from my perspective this helps a great deal and rings true.
From an utterly unscientific viewpoint (although firmly evidence based!) I can think of real, living and breathing people who fall into each of the categories – and, as you say, have different needs as a result.
Thanks for this – very interesting
I think it helps a great deal, and I would like something more along these lines to replace the “cycle of change” which i think has been used as the gospel for too long (and was based on smokers who are different to substance abusers). I think my main problem with the MI/Motivation to change workshops is that it is a one size fits all approach and it tends to focus on those who were at the no-change stage (or pre-contemplation if you use the cycle of change model).
As you know the substance replaced category is a massive problem in Tameside, I suspect it is pretty much the same in the rest of the country as well.
Then you also have the issue of how you deal with those who have lapsed and relapsed in the context of an abstinence or recovery based service.
We need to address all these issues in a system which doesn’t discriminate, or segregate when it is unnecessary. I don’t have the answers, and I suspect few people do. Maybe that is why there is little being said at the moment.
Thanks Simon,
It does help because we need to start thinking about segmenting the treatment population and this work contributes. We need an idea of % guestimations of how many might be in each of these 5 ‘segments’. As Matthew says we suspect that the Substance Replaced group is significant (if this is the group that just pick up a methadone prescription from us). The question is how big? People will say things like “there are too many people on methadone” we need to know how many is too many. Conversely, “we need more people to be going into abstinence based recovery” OK how many more and how do we identify them? As a starter for ten, and focusing on Tameside (about 1000 in treatment?), I suppose you could ask – how many are in each segment 1) Recovering 10%? 2) Stalled 20% 3) Substance Replaced 40%? 4) Relapsed 20%? 5) No Change 10%? Next question then is to put the funding available pie chart alongside this 5 segment pie chart and see what the taxpayer is currently getting for their investment in Tameside (say £4 million with everything included?). This is the kind of exercise we do all the time when working with English DAATs to design and re-design treatment systems. For example, Wirral DAAT now direct almost 30% of their pie chart toward recovery
Thanks for this Simon. I can definitely think of examples of people in each of the stages described. I think this type of work is particularly (or, only) helpful when we translate the findings back to real life and use them to feedback to service provision/development/emergement (word?!), training, attitudes and most importantly, the messages we give people in each stage. In terms of ERO (emerging recovery organisations), we can learn a lot from this as we seek to understand and shape the services we aim to offer. Listen to the people! Stage 2 highlights something that I think about a lot and which we were discussing in group last week. We were talking about the difference between ‘white-knuckling’ it (i.e. the drug is not being taken but the individual’s life is still dominated by it, the consequences of their past using and so on) and ‘moving on’ (i.e. a feeling of life and personal development, freedom, change – whatever this might be for the person). Is it naive to want to create systems to measure ‘success’ / ‘recovery’ in deeper terms than ‘using / not’; ‘crime / not’. Or is this something for practitioners/peers/service providers to consider and address but not expect measures to be able to well, measure. Hmmm!
