2024’s Top Posts – #4 – The war against ‘pathology porn’: How can we make recovery research strengths-based and generative

by David Best, Sharynne Hamilton, Noreen Demeria, Tom Karl

The problem 

Assessments for drug and alcohol treatment are generally miserable affairs. For both parties. As a result of worries about governance, risk, safety, funding etc, the person seeking help is often confronted by a ‘professional’ armed with a questionnaire that is made up of standardised research instruments and clinical assessments, that attempt to document everything that has gone wrong in a person’s life – physical health, mental health, relationships, diseases, crime and justice system involvement, family challenges, trauma, homelessness and money, being among the most common areas of investigation. 

The assumption is that you lay your (bad) cards on the table and we will help you to deal a better hand. The person seeking help is encouraged to be open and honest to a stranger they may well never have met before, and who they may never actually see again, depending on whether the ‘intake worker’ actually has a caseload in the treatment service. 

No area is out of bounds – current drug using and sexual activity, inner traumas and fears, diseases and disorders, all offered up for diagnosis and prognosis. ‘Evidence-based practice’ for both drug and alcohol treatment suggests that, if you stick with the programme, this big list of deficits and pathologies will diminish – less crime, less injecting, less drug use, less drinking, less psychiatric problems, less physical health problems. 

That is all well and good, assuming that there is no gaming and planned reporting either here or at the follow-up points. As the great John Davies alluded to in the “Myth of Addiction” (Davies, 1990), this is a socially structured process that results in answers to ensure that at least one of the two parties in the room gets what they want, and that the question of whether it is ‘true’ or not as an artifactual one. 

The topic of interest here, however, is not the product but the consequence of this interaction – the disempowerment of the person seeking help through a process that emphasises the status differential and the generation of what we will refer to as ‘pathology porn’. This is a voyeuristic glorification of ‘complexity’, ‘co-morbidity’ or ‘multiple vulnerability’ that excludes and labels and disempowers, frequently taking in domains far removed from the causes of help seeking in the first place.

The recovery response: the transition to a strengths-based approach

The recovery approach fundamentally attempts to reverse this model through the following paradigmatic shifts:

• By measuring strengths more than deficits
• By removing the process from the clinic to the community 
• By assuming the relationship is not that of expert-patient but that it is an equal partnership
• By focusing as much on networks and communities as what is happening in people’s bodies as in their heads

What that has meant in practice is to ask people at the first contact point what they want and what they are good at and interested in, and in treating them as a unique individual, not as a case to be processed.

The recovery approach has also been intrinsically linked to peers and lived experience. Not only does this afford the opportunity for role modelling and social learning but also means that the ‘professional’ does not present as a de-humanised representative of a service but as someone who has (and frequently is) walking the same path and who will own their own vulnerabilities and limitations. It is a uniquely human encounter between people both of whom should be looking to grow as a result of their contact and the resulting relationship.

So what are the implications for recovery research?

There are two basic lessons here, the first of which I think has already been learned:

1. Questions have to be strengths-based and positive – and ideally allow for freedom of expression for people to put their own stamp on their responses. This does not mean that there is no place for standardised measures (like the Assessment of Recovery Capital or the REC-CAP) but that they should be embedded in interviews that also allow for individual narratives and future plans and processes.
2. The second issue is only something that recovery researchers are slowly coming to terms with and that is the avoidance of the clipboard and the long questionnaire. Apart from the fact that, for some people, this is inherently triggering, it also risks provoking the usual triumvirate of tut, sigh, eye roll! We need to use more imaginative methods to collect our data. There are a few examples given below:

Yarning circles: are group activities used for data collection in qualitative research, that utilise themes for discovering the views and experiences of group members. It is a flexible form of data collection and is particularly useful for considering the needs of more vulnerable participants, who may require additional tools or supports (Hamilton et al., 2020). For Indigenous peoples, yarning is a form of “cultural conversation” (Bessarab & Ng’andu, 2010, p. 37) where control is shared, and connections are built. Utilising yarning circles allows for the flexibility researchers require to build rapport and trust through finding common ground in the group, conducting relational exchanges, and establishing group cohesion. Yarning, then becomes a tool of authentic information exchange, which when done respectfully and by mutual agreement, has the potential to reveal rich information that promotes the collective hopes of the group. Through a process of sharing knowledge and finding common ground, yarning becomes a journey of mutual discovery and learning. Promoting positive individual and group benefits and outcomes.

R1 Learning and Recovery Capital cards 

The R1 Learning System provides an interactive set of tools that enable individuals to:

• Learn about themselves concretely through the lens of evidence-based models and theories,
• build their vocabulary,
• identify strengths and gaps,
• express themselves more effectively to themselves, peer support providers, family members, and an array of healthcare professionals on their journey,
• Set SMART goals,
• Build internally motivated recovery plans.

The Recovery Capital cards have been piloted in UK recovery services to considerable enthusiasm from recovery coaches and their clients as something visual, attractive and easy to use and comprehend. What is more several clients have taken away the cards and used them with family members, suggesting a level of engagement and ownership that is not possible with traditional ‘therapeutic’ approaches. 

Photovoice: is a method for combining data collection with creative approaches to storytelling that was used in the European Recovery Pathways study (REC-PATH; De Maeyer et al, 2023) and is currently being used in a study of women’s recovery experiences in the Balkans, UK and Sweden (Nisic et al, in preparation). What is particularly important about this project is that, as well as co-producing the dissemination of the photographs and narratives, the participating women have bonded into a supportive group that will outlive the doctoral research project.

But this is only in part a call for recovery researchers to be more imaginative and innovative in their methods. It is primarily a call for recovery research to fulfil the criteria of CHIME (Leamy et al, 2013). The ethics of recovery research should do much more than ‘no harm’ and should aim to:

• Create new positive Connections and relationships, including authentic relationships with the researchers
• Generate Hope in participants as well as all those who subsequently engage with the research
• Create a positive and inclusive Identity for those who participate in the project
• Both to capture Meaning in the lives of participants and to actively contribute to this through opportunities for participant engagement at different stages of the research process
• The research should be intrinsically Empowering to all of those who take part in recovery research

This should be a checklist for recovery research ethics that should be combined with innovation and creativity in research design to ensure that the foundation for recovery research should be generativity. This goal will not always be possible but aspiration should be central to recovery research an ideal that should influence research across the social sciences.

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References

Bessarab, D., & Ng’andu, B. (2010). Yarning about yarning as a legitimate method in Indigenous research. International Journal of Critical Indigenous Studies, 3(1), 37–50. https://doi.org/10.5204/ijcis.v3i1.57

Hamilton, S., Reibel, T., Maslen, S., Watkins, R., Freeman, J., Passmore, H., Mutch, R., O’Donnell, M., Braithwaite, V., & Bower, C. (2020). Disability ‘in-justice’: The benefits and challenges of ‘yarning’ with young people undergoing diagnostic assessment for Fetal Alcohol Spectrum Disorder in a youth detention centre. Qualitative Health Research, 30(2), 314–327. https://doi.org/10.1177/1049732319882910