The Unspoken Shift From Quality to Quantity Standards In Substance Use(r) Treatment and Prevention: A Challenge to Unfinished Intervention Business

Abstract

A common flaw when dealing with substance use and misuse is the over-inclination to (re)-act; a reflexive “knee-jerk” and not a well-planned act which is theoretically and empirically informed. It seems that a shift from quantity-driven standards back to quality-driven standards would be best achieved by encouraging politicians, stock holders, and decision makers to question more, before financially supporting any prevention intervention.

Keywords:

• standards
• prevention
• evaluation
• quality
• quantity
• slow(ness)
• decision makers

Notes

¹ The journal's style utilizes the category substance abuse as a diagnostic category. Substances are used or misused; living organisms are and can be abused. Editor's note.

² Treatment can be usefully defined as a unique, planned, goal directed, temporally structured, multi-dimensional change process, which may be phase-structured, of necessary quality, appropriateness and conditions (endogenous and exogenous), implemented under conditions of uncertainty, which is bounded (culture, place, time, etc.), which can be (un)successful (partially and/or totally), as well as being associated with iatrogenic harm and can be categorized into professional-based, tradition-based, mutual-help based (AA,NA, etc.) and self-help (“natural recovery”) models. Whether or not a treatment technique is indicated or contra-indicated, and its selection underpinnings (theory-based, empirically-based, “principle of faith-based, tradition-based, budget-based, etc.) continues to be a generic and key treatment issue. In the West, with the relatively new ideology of “harm reduction” and the even newer Quality of Life (QOL) and “wellness” treatment-driven models there are now new sets of goals in addition to those derived from/associated with the older tradition of abstinence- driven models. Conflict-resolution models may stimulate an additional option for intervention. Treatment is implemented in a range of environments; ambulatory as well as within institutions which can also include controlled environments such as jails, prisons and military camps. Treatment includes a spectrum of clinician-caregiver-patient relationships representing various forms of decision-making traditions/models; (1). the hierarchical model in which the clinician-treatment agent makes the decision(s) and the recipient is compliant and relatively passive, (2) shared decision-making which facilitates the collaboration between clinician and client(s)/patient(s) in which both are active, and (3) the ‘informed model’ in which the patient makes the decision(s). Within this planned change process, relatively recently in various parts of the world, active substance users who are not in “treatment”, as well as those users who are in treatment, have become social change agents, active advocates, and peer health counselors…which represent just a sampling of their new labels. There are no unique models or techniques used with substance users- of whatever types and heterogeneities- which aren't also used with non-substance users. The reality that substance users, representing a heterogeneous group of people, patterns of use and life styles, continue to be treated in ‘specialized’ programs which are distanced from the mainstream of the treatment of non-users –“NORMED TREATMENT OF NORMED DISEASES”- and all-too-often manifest imparity in availability, accessibility and delivery of needed services, utilize policies which are stakeholder –driven and not evidence-based and may be ethically-insensitive, does not change the reality that there is no “drug treatment”; no “alcohol treatment.” Part of the “unfinished business” associated with the treatment of substance users, when needed and appropriate, relates to knowing, understanding and being able to effectively utilize when treatment is (1) indicated, (2) contra-indicated, (3) irrelevant and, at times, can be (4) regressive. Editor's note.

³ The reader is referred to the web site www.edge.org as a source for considering questions and answers. The works by the urban planner Horst Rittel and the cosmologist Heinz Von Foerster are also relevant. Horst Rittel and Melvin Webber suggested that problems can and should be usefully categorized into two types: “tame problems” and “wicked problems” The former are solved in a traditional linear analytic known and tried “water fall paradigm”; gather data, analyze data, formulate solution, implement solution. The latter “wicked problems” can only be responded to individually, each time anew, with no ultimate, repeatable solution. From this perspective substance use is a wicked problem. (Rittel, H. and Webber, M. (1973). “Dilemmas in a General Theory of Planning”. Policy Sciences, Vol. 4, pp 155–169). The cyberneticist Heinz Von Foerster posited that there are two types of questions; legitimate and illegitimate ones. The former are those for which the answer is not known and is, perhaps, even unknowable during a given state of knowledge and technology- the effective control of man's “appetite” for a range of psychoactive substances, whatever their legal status An illegitimate question is one for which the answer is known, or, at the very least consensualized. An illegitimate question is one for which the answer is known, or, at the very least is consensualized enabling t-he creation of a state of temporary or more permanent query-closure. The quest within a question becomes guaranteed. The asking of illegitimate questions has been, and remains, by and large, the acculturated norm. Heinz Von Foerster, Patricia M. Mora, and Lawrence W. Amiot, “Doomsday; Friday, 13 November, A.D, 2026,” Science, 132, 1960. pp. 1291–1295. The reader is referred to Pablo Neruda's The Book of Questions for a poetic exploration of legitimate questions. Editor's note.

⁴ The reader is asked to consider the merit of the American author, Robert A. Heinlein's, point of view about experts and specialization. He posited that a human being should be able to change a diaper, plan an invasion, butcher a hog, conn a ship, design a building, write a sonnet, balance accounts, build a wall, set a bone, comfort the dying, take orders, give orders, cooperate, act alone, solve equations, analyze a new problem, pitch manure, program a computer, cook a tasty meal, fight efficiently, die gallantly. Specialization is for insects. Editor's note.

⁵ The reader is referred to Tilly, Charles (2006). Why. Princeton Univ. Press. Princeton, NJ for a stimulating analysis about generic “causative” reasons given in the West and to Tilly, Charles (2008). Credit and Blame Princeton Univ. Press. Princeton, NJ for an important analysis about “blame.” Editor's note.

Additional information

Notes on contributors

Moshe Israelashvili

Moshe Israelashvili, PhD, Israel, received his PhD in Social Psychology from Tel Aviv University, Israel. He teaches in the School Counseling Program, The School of Education, Tel Aviv University. He is a co-editor (with John L. Romano) of Cambridge Handbook of International Prevention Science (in preparation; Cambridge University Press). His areas of interest include prevention of maladjustment, stress inoculation, resilience promotion, school mental health.