Treatment: nothing less than flourishing!

We should fight to ensure our patients and this field does not accept anything less than flourishing – that should be the goal we bring to our work in research and clinical practice.

Eric Strain

I grew up in Glasgow, a city whose motto, as every schoolchild was taught, is ‘Let Glasgow flourish’. I think primary school was probably my first introduction to the word flourish which my dictionary tells me means ‘to grow luxuriantly, to thrive, to be in full vigour and to bloom’. 

Tyler Vanderweele widens this definition^[1] and makes the point that, applied to human lives, flourishing encompasses happiness and life satisfaction, meaning and purpose, character and virtue, and close social relationships. 

When I reflect on this deeper meaning, the elements chime with me. These are the things that matter most to me. They certainly matter to the patients I look after and support who are trying to achieve recovery from substance use disorders. Most people would probably agree; these things are important.

It’s puzzling then that much of the biosocial literature looking at recovery from physical and mental health conditions does not consider such issues, concerning itself with narrow end-points and measurements, perhaps because these are of more interest to researchers than they are to the people with the conditions, or simply that they are easier to study.

Eric Strain took up this theme recently in a valedictorian editorial^[2] in the journal Alcohol and Drug Dependence on the subject of purpose and meaning in the context of opioid deaths. He expressed his concerns:

The substance abuse field in both its research as well as treatment efforts is not giving due consideration to flourishing. We need to renew our efforts to give meaning and purpose to the lives of patients.

While praising the essential goal of reducing opioid overdose deaths, Strain argues that this is ought to be a starting point – not an end point. 

If a patient with a significant leg wound has the bleeding stopped with a compress, the medical field does not declare victory. Providers clean the wound, stitch it, arrange for physical therapy for the leg, and work to maximize the functioning of the person.

His wish is that we focus on helping not just to reduce drug deaths, but on helping people grow and flourish. Perhaps with the recent debates over the definition of ‘recovery’ and the controversies surrounding it, we could focus on flourishing as a concept.

With the patient’s consent, I have a series of pictures on the noticeboard in my office which capture images of an ex-service user at three stages in his recovery journey. The first was taken on the day of admission to rehab, the second on his discharge and the last a couple of years later. It’s hard to believe it’s the same person, such is the physical transformation. 

Now while this is impressive, it’s not nearly as impressive as the things the picture cannot capture – his wellbeing, his enthusiasm, his self-esteem, the pride in his business, his willingness to help others, the quality of his relationships – all as important to him as his physical health and appearance.

So, how much flourishing really is going on in treatment settings? Professor David Best recently wrote^[3]:

Recovery is frequently blocked not through failings of the person themselves but through the stigmatising attitudes of a range of ‘professionals’ who stymy the ambitions of their clients and whose own scepticism about recovery colours and corrupts their work.

Now, I am fortunate to work in a wider NHS treatment environment and also with voluntary sector partners where I am much more likely to see the opposite of this, but sadly, I have also heard stories more widely (some very recently) from patients and their advocates of blocks to recovery and therefore, blocks to flourishing. Lack of hope and ambition for clients/patients is often at the heart of such barriers, though so are issues of work overload and inadequate resources.

In medical school, I learned that health is not merely the absence of disease. In the same way, recovering from substance use disorders cannot only be about reduction in deaths, essential though that is, or reduction in crime, reduction in substance use, reduction in blood borne virus transmission etc. As I’ve argued before, we have to square worthy public health goals with what matters to the individual and their family – namely, the key elements of flourishing. These are the positives that need to accrue at the same time as the negatives recede.

In a 2017 article in the Journal of the American Medical Association^[4], Vanderweele and colleagues point out that focussing on the health of the body might conflict with other goals that are actually important to individuals. They also argue for the value of the benefits of population-level flourishing and of making flourishing relevant to clinicians too, to prevent burn-out.

There are tools to measure flourishing which could compliment those which capture recovery capital and outcomes, but it is the concept and potential of moving to a model predicated on the value of flourishing that engages me. In Scotland, much effort has gone into developing a trauma-informed workforce. I wonder if we did the same with flourishing in mind – a flourishing-oriented professional group perhaps – if we would see transformation in both the workforce and in the quality of service-users’ lives.

Professor Best reminds us that recovery is often achieved through ‘an intense series of interactions that generate hope and trust.’ This week I’ve seen several rehab patients with non-addiction related health issues. When seeing them I think I’ve been interested, cheerful and thorough, but now I wonder what would happen if I had gone into every consultation with that goal in mind – the generation of hope and trust and a desire to see them flourish beyond helping them solve their minor ailments. 

I realise I sometimes fall short in this regard, but also that it won’t be that difficult for me to do a bit better. What if all of us in the field took that approach with everyone? What if we did not accept anything less than flourishing as an outcome? I think this might have a profound effect not just on those we work with, but on ourselves too.

Continue the conversation on Twitter @DocDavidM

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^[1] VanderWeele TJ. On the promotion of human flourishing. Proc Natl Acad Sci U S A. 2017 Aug 1;114(31):8148-8156.

^[2] Strain EC. Meaning and purpose in the context of opioid overdose deaths. Drug Alcohol Depend. 2021 Feb 1;219:108528.

^[3] Best, D. 2021 Research and the Recovery Movement. https://www.rec-path.org/blog/research-and-the-recovery-movement-science-and-advocacy

^[4] VanderWeele TJ, McNeely E, Koh HK. Reimagining Health-Flourishing. JAMA. 2019 May 7;321(17):1667-1668.