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Published on April 9, 2008

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From faith to knowledge?:  From faith to knowledge? Reflections on some prerequisites for evidence-based addiction care in Sweden 10th International Symposium on Substance Abuse Treatment Reforms, ideology and best practise Oslo, 1-3 October 2007 Addiction care in Sweden – some background facts:  Addiction care in Sweden – some background facts New millennium and new prerequisites in the substance use field::  New millennium and new prerequisites in the substance use field: Alcohol: Accession to the EU dismantling of traditio- nal restrictive policy  increasing drinking; perceived need to find alterantives New interest in addiction care - demands for better outcomes and increasing resources Narcotics: Increasing abuse; increasing mortality  ambition to strengthen traditional policy Main strategies::  Main strategies: The development of ”evidence-based practices” - Review of ”effective treatment methods” (RCT-studies; SBU, 2001) - National guidelines for adiction care (NBHW, 2007) More resources for the care of ”heavy” addicts: - Economic incentives to use more coercive care - Local projects to develop ”care chains” Improved documentation The new initiatives: hopes, possibilities - and some problems:  The new initiatives: hopes, possibilities - and some problems Indications that a better knowledge base is needed:  Indications that a better knowledge base is needed Slide7:  ”Not the continuous march of progress in science, but persistent frustration with the lack of progress in fighting alcoholism” (Kettil Bruun, 1971) Shifting therapeutic crazes - “one ‘wonder-cure’ for each decade” (Lindström, 1994) Overarching, economic and political-ideological changes and considerations – “a common solution to different problems” (e.g. Mäkelä et. al., 1981) What has governed the historical succession of efforts to solve addiction problems? Slide8:  1916 – 1950s: Disciplining/ keeping up of social order (the addict as ”dangerous”/morally inferior) 1960s – 1970s: ”The producers’ paradise” (Bergmark & Oscarsson, 1994) (increasing trust in the welfare state and in treatment as a solution to various human troubles; ideological convictions and shifting therapeutic crazes (“anything goes”); culmination of alcohol care) 1980s: ”From ideology to economy” (Blomqvist, 1996). (”marketisation”; buyer/seller-systems; ”offensive drug care”) 1990s: Economic recession; addiction care set aside ”100 years of substance abuse care in Sweden”: How do professionals choose what to do? A vignette study. Exampel 1: type of intervention for five ”cases” ( > 200 professionals at > 30 units ):  How do professionals choose what to do? A vignette study. Exampel 1: type of intervention for five ”cases” ( > 200 professionals at > 30 units ) (Blomqvist & Wallander, 2004) How do professionals choose what to do? A vignette study. Exampel 2: type of treatment for five ”cases”:  How do professionals choose what to do? A vignette study. Exampel 2: type of treatment for five ”cases” (Blomqvist & Wallander, 2004) How do professionals choose what to do? Exampel 3: proportion at each unit that recommended coercion:  How do professionals choose what to do? Exampel 3: proportion at each unit that recommended coercion (Blomqvist & Wallander, 2004) Some conclusions::  Some conclusions: Low professional consensus (ideology; theory; terminology) Differing views on alcohol and drug problems (the drug addict more alien and worse out) Large between-unit differences (what you get depends on where you live) Large within-unit differences (what you get depends on who you meet) Lacking legal security (coercive care) Few ask for the client’s own opinion Everyone is not judged alike – but economy, local traditions, and ideology as important as – or more important than – clients’ needs and whishes The official picture of addiction care:  The official picture of addiction care National Board of Health and Welfare on addiction care (2005): … There are good examples, but … Interventions are often ad hoc and ill planned, and treatment is often interrupted … Intense (but often unsuccesful) treatment attemps alterante with long periods without support … Relapse seems to be the standard outcome of fragmented interventions Evidence-based practice guidelines – some pros and cons :  Evidence-based practice guidelines – some pros and cons Arguments in favour of EBP::  Arguments in favour of EBP: Humanism: - focus on outcome, not on legislation/procedural rules or on ”filling beds” (clients’ welfare, rather than staff’s comfort or safety) Certainty: - focus on facts, not personal convictions or beliefs (what actually works, rather than guesswork or ”sunshine stories”) Utility, economic rationality: - tax payers can’t afford that money are spent on activities that do not effectively solve the problems in question Swedish National guidelines (2007) – brief summary::  Swedish National guidelines (2007) – brief summary: Alcohol : Psycho-social treatment: 12-step program (manual based) CBT (focus on drinking) Community Reiforcement Approach Brief interv./Motivational interview. Interactional therapy Dynamic therapy Family therapy (focus on drinking) Behav.ther. + ind. adapted support (”heavy abusers”) Pharmacological treatment: Acramprosate/naltrexone (+ psychother.) (+ antabuse, controlled adm.) Should not be used: ”unspecific support” ear acupuncture antabuse (uncontrolled; implants) Drugs: Psycho-social treatment: CBT (cocain) abstention/cognitive training (cannabis) General: same methods as for alcohol (evidence disputed) Pharmacological treatment: Methadone and buprenorphine (opiates; comb. with psycho-social treatment) Antabuse (cocaine) Should not be used: ”unspecific support” No RCTs of treatment of amphetamine abuse No superior method – but no clear support for any ”matching” strategy either Actual vs. recommended methods in Swedish addiction care (National guidelines, 2007 vs. national inventory, 2005):  Actual vs. recommended methods in Swedish addiction care (National guidelines, 2007 vs. national inventory, 2005) Social skills training (32 %) Ego-strengthening therapy / suport (31 %) 12-step treatment / Minnesota model (25 %) Cognitive behavior therapy (19 %) Solution-focused treatment (16 %) Social-pedagogical model (responsibility training) (11 %) Motivational interviewing (10 %) System-theoretical model (10 %) Behavior therapy (10 %) Acupuncture ( 9 %) ………………… Community Reinforcement Approach – CRA ( 1 %) ……………….. About 1/3 of all units offer medicine-assisted treatment Slide18:  RCTs useful /needed for: Valid causal inferences Discarding of ineffective and harmful methods Basis for resource allocation - aggregate level However: The most practiced metods have not been studied in RCTs (what is ”unspecific support”?) Ever-changing knowledge base (guidelines may be obsolete before publishing) Moderate effects; control groups change as well Results at group level not necessarily valid at individual level (but we know little about what is best for whom) ”Method” explains only part of the outcome variance Limited external validity (only treated persons; selection and standardization of therapies, therapists, clients) Short-term consequences of time-limited interventions (but what happens before, outside of, and after the treatment is also important) Slide19:  (Lambert et al., 1992) Dividing the outcome variance pie Who are the clients?:  Who are the clients? ”A goup of social outcasts” (The state of temperance care; 1967) The proportion of marginalised persons in in-patient addiction care increased considerably from 1983 to 1993 (Blomqvist, 1996) - Clients in social services based addiction care in Stockholm: 74 % men; 79 % single; 85 % not in work; 54 % no permanent housing; 38 % primary school at most; 6 % not treated before (Eriksson et.al., 2003) Clients in health care based dependence care in Stockholm: 70 % men; 73 % single; 77 % not in work; 35 % no permanent housing; 30 % primary school at most; 9 % not treated before (Palm & Storbjörk, 2003) Previous treatment experience and external pressure - rather than severity of drinking – main predictors for being in alcoholism treatment (Storbjörk & Room, 2006) Heterogenous problems: who have been studied and who are treated?:  Heterogenous problems: who have been studied and who are treated? RCT-studies Addiction care Slide22:  Previous drinking: ”Problem consumer” Dependent (ICD-10) Present drinking: How important is treatment? (Blomqvist et al., 2007) Proportion who improved their drinking habits without treatment; representative population sample; N= 339/ 2862 ”Risk consumer” ”Moderate” Abstainer 94 % 90 % 85 % 55 % 72 % 48 % 83 % 44 % 28 % ”Normal” Swedish addiction care in sum::  Swedish addiction care in sum: Rather limited role in ”curing” addiction problems Large resources are spent on a small group with severe social and psychological problems, who turn up repeatedly Persons with less severe problems / earlier stages / with better social resources are not reached by / reluctant to contact the treatment system (low availability / fear of stigmatisation /low confidence in existing treatment) Low professional consensus and little collegial dialogue (what you get depends on where you live and who you meet) Local traditions, economy and ideology mean as much as – or more than – research-based knowledge / documented experience EBP in a wider perspective :  EBP in a wider perspective The challenge::  The challenge: The official/manifest goal: to make people stop using narcotic drugs and (ab)using alcohol (Government action plans on alcohol and drugs) The actual / latent goals: Diminishing suffering & mortalilty /creating more tolerable life conditions/ relieve some pressure from relatives and friends (Lindström, 1994) ”Controling the uncontrolable” (Bergmark & Oscarsson, 1988) Assisting society in ”living with its addicts” (Kühlhorn, 1983) Given that both aims are legitimate, what could and should be done to adapt what is done to variegated and heterogenous needs in a variegated and heterogenous group of people with a variety of addiction problems? 1. Facilitating self change / helping people help themselves:  1. Facilitating self change / helping people help themselves Counteract moralism and simplistic categorisations. See addiction as a life style problem / ”environmentally responsive behavioral health problem” Teaching that self-change is possible and how the environemt may help ( about ¼ has someone close who had an alcohol problem; 1/10 tried to help; Blomqvist, 2006) Options to evaluate own consumption habits / easily available advise / reliable self-help materials (web sites, telephone ”help lines” a s o) Encouraging different kinds of ”mutual help”- and support groups Easily accessible / brief / attractive forms of support (no clear border between ”self change” and ”treatment”) Social policy interventions to create sound alternatives (Blomqvist, 2006; Blomqvist et al., 2007) 2. Making services attractive and relevant to the large majority of problem users:  2. Making services attractive and relevant to the large majority of problem users High availabilty / support on demand (”motivation is perishable goods”) ”Start where the individual is” Assessment/planning/choice of intervention in dialouge with the client ”To each according to his needs” – not ready-made ”care chains” (specific or global interventions; assessment/brief advise/treatment/long-term support) Continuous follow-up/revision of plans - in dialouge with the client Broad menue of approved methods and supportive interventions Cross-disciplinary team (”bio-psycho-social”; joint organisation?) Co-operation with the environment (other help systems; ”natural healing forces”) (Blomqvist, 2003) 3. Improving the situation of the ”heavy” addicts or ”chronic cases” – do we need new resources or new ways of thinking?:  3. Improving the situation of the ”heavy” addicts or ”chronic cases” – do we need new resources or new ways of thinking? Some points of departure: Continuity is crucial: long-term problem require long-term support No evidence for the benefits of long-term coercive care No intervention is as influential as ”the natural environment” Own choice → stronger committement / positive expectations → better outcome Good relation / working alliance is crucial Less intense consumption / improved life quality is acceptable goal ”From intensity to extensity”: Rather than irregular, intense, and often interrupted interventions (coercive institutions, treatment homes a s o): continuous, less intense contact (”generic counselor”; personal ”ombud”) – varying forms of support when needed, mobilisation/strengthening of ”healing forces” in each person’s life context; swift and adequate interventions in ”acute” situations (Humphreys & Tucker, 2002; Blomqvist et.al. 2007) Three interpretations of EBP::  Three interpretations of EBP: The informed practitioner – consulting research data bases for each individual case The guidelines-directed and manual-abiding practitioner The pragmatic practitioner – trying to balance scientific evidence, well-documented clinical experience, and clients’ needs and whishes (cf. Sacket et al., 1997) How to keep the learning process going? Slide30:  Can the informed practitioner’s strive for certainty lead to blind faith? Ever new studies  increased transparency  increased uncertainty  new beliefs? Doe’s the manual-abiding practitioner work in the client’s interest? Is it more humane to abide by the letter of the manual than by the letter of the law? ”Technicalisation” may lead to dehumanisation (Bauman on Milgram) Potential paradoxes: Developing a basis of well-documented clinical experience and professional consensus ::  Developing a basis of well-documented clinical experience and professional consensus : Systematic documentation – follow-up – collegial dialouge at the practice level Research needs: More controlled outcome studies (real life treatment methods/techniques) More studies of the treatment process and ”common factors” (e.g., more knowledge about the role of faith in recovery) More long-term, naturalistic studies; user’s perspective; organizational aspects, a s o Putting the single client i focus: Keeping track of the development of the single case (corrections / adaptions to new circumstances / increased motivation / better outcome) How to strike the balance? Slide32:  On the move from ”faith” towards ”knowledge”: (bridging the gap between research and practice) Research: contribute ’abstract’ knowledge (causes; methods; principles) (advise practice on documentation and self-scrutiny) Practice: (translate and adapt abstract knowledge to shifting concrete circumstances) Scrutinise, articulate and systematise own experiences … in dialouge with users/clients… and… on-going ethical discussion

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