Can Nordic alcohol and drug treatment benefit from a recovery perspective?

One could easily make a long list of imports and translations to the Nordic region of treatment perspectives from other countries, mostly the US and the UK. Sometimes these travelling models have been linked to layperson movements (AA), sometimes they have been underpinned by a professional or semi-professional activity (therapeutic communities). Often, the spread of a treatment model has been connected to new technologies (such as methadone for substitution treatment). It is of course no wonder that the Anglo-American world, with its dominance in research and research publishing, has been the most important sender.

“Recovery” could be added to this list of travelling treatment perspectives. As David Best shows in his stimulating text in this issue (Best, 2017), “recovery” is a very broad and rather loosely defined concept – a fat word in the long list of words that can be found in the alcohol and drug policy field (cf. Edman, 2009). A person’s recovery shall, according to the US and UK definitions, be measured not only in terms of reduction of (or total abstinence from) alcohol and drug use, but also as improved general health and active participation in society. In another context Best has stated that recovery involves a sense of belonging, of leading a meaningful life, of having hope and a positive identity (Clark, 2013).

Good?

Recovery thus defined is not only about consumption, but about well-being, even happiness, social inclusion and empowerment. As a vague concept it is open to different operationalisations and emphases, and can easily be used by different actors for their various purposes. Maybe this vagueness has also been a key to the formation of a recovery movement, at least in the US, which has united problem users, their families, mutual support organisations, professionals and researchers. At a recent Norwegian conference, different attendants used the concept to refer to treatment where the goals are defined by the patient rather than the staff, to indicate a model for integration of health and social care where good everyday life rather than pathology is in focus, as a road from addiction to abstinence, or as a way to handle stigma (Renland, 2016). As Renland notes, the concept seems to be able to cover all contemporary treatment ideals.

When adapted as a guiding principle at a treatment system level, the meaning of recovery will depend on the prevailing views on alcohol and drug problems and the existing institutions that handle these problems. The translation is also framed by the political, civil and social rights in society and how they apply to persons with alcohol and drug-related problems. All these aspects make up the conceptual field and political background against which “recovery” shall stand out as a promise of new solutions. Best (2017) notes the variations in the translation of recovery from the US to the UK, and how Scotland implemented recovery in a different way than England. Even someone who is not an expert on the US or UK systems can conclude that the differences in criminalisation of drug use, in the dominance of AA philosophy, in the application of substitution treatment or in the use of New Public Management (NPM) are important explanatory factors behind these various translations.

In the Nordic context, recovery could introduce a welcome broadening of the too-narrow focus on evidence-based treatment methods as solutions to substance-use problems that we have seen much of lately (see for instance Ekendahl, 2009). And with the increasing acceptance of substitution treatment – as Bengt Svensson also pointed out at a seminar in Copenhagen on recovery in November 2016 (Stenius, 2016) – we have seen a strong medicalisation of the drug treatment perspective in all Nordic countries, which calls for a re-enforcement of the social perspective (see below).

Bad?

Best’s text can also be read as a warning against interpretations of and circumstances around the adaptation of the concept, that de facto will threaten rather than improve provision of treatment, especially for persons with more severe or complex problems. In the UK, recovery, as Best notes, was introduced at the same time as social policy reforms to save treatment costs. Generous substitution treatment threatened to become a long-term expense, with the large population of opiate users. Pressing treatment providers to deliver abstinence, if possible with the (free) support of laypersons could, at least in the short run, promise to save healthcare costs. In the Nordic countries we should at least avoid this translation of the recovery perspective.

Unnecessary?

The recovery perspective has so far not gained much attention in the Nordic countries. Norway is the possible exception; the Nordic country where alcohol and drug-abuse treatment is most closely linked to psychiatry. Cultural conceptions of alcohol and drug problems change slowly. Spontaneously, one could think that we do not need to import recovery. It is no coincidence that the word “recovery” is foreign in the Nordic languages, as Recke (2017) points out, with no good translation. Nordic alcohol and drug treatment has been rooted in social work for more than one hundred years. We have used social and economic criteria, rather than genetics or diseases of the brain, to determine whether a person has alcohol and drug problems or not and in trying to solve them. We have believed in the educative role of work, and emphasised the importance of family and the broader social community, including mutual support movements, as crutches for the troubled misuser. Why import something when we have local models with the broad perspective?

Unrealistic?

We may be proud of our Nordic treatment, which is extensive, affordable or free, comparatively professional, with a social work dominance but also including a medical perspective. However, stigma and marginalisation have not disappeared from our systems.

One reason for this lies in our history. Treatment of substance-use problems has its institutional roots in local (municipal) poor relief. Municipal decisions about the distribution of tax money was the financial base of care. Alcohol abusers belonged to the group of undeserving poor, who with their own behaviour had caused problems for themselves and to those around them, and costs for decent taxpayers. Rights to services had as a rule to be deserved by economic contributions to society, and those who neglected their duties had to be reformed with harsh educative measures.

At the meeting in Copenhagen, Best described a project in an English town where former prisoners with drug problems received both good housing and vocational training, and even challenged the stigma by branding themselves as construction workers with a substance-abuse background. Their story demonstrated that this handling of problems was a much more successful road to abstinence than treatment only.

My final question: is this kind of thinking about ways out of problematic use unrealistic in our Lutheran and municipal Nordic tradition? Would we accept treatment plans that look at guaranteed housing, and education or work, as the necessary frame for psychosocial or medical treatment and preconditions for a successful new start? Given the difficulties with “housing first” in at least some of the Nordic countries, I have my doubts.

Conclusion

The recovery movement has produced some interesting research and interventions that in a welcome way emphasise social and societal support and the importance of participation. I believe that they can give important inspiration also for Nordic treatment.

A recovery movement is another matter. I am somewhat sceptical of the need for such a movement, not least in light of the present strength of NPM and its shaping of the application of the perspective. And I am uncertain if it is even possible to establish. With a very different treatment system tradition than in the Anglo-American countries, the concept and perspective may become so diversified that – unlike in the United States – it will not be able to unite the different actors.