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An update to the 2022 article by Jon Fisher
Having been on a journey of vast professional development over the past 18 months since writing the original article, I felt compelled to share my learning and reflections from developing the role of occupational therapy within an established substance use service. It is my hope that service users, somewhere, may benefit from sharing my experience with like-minded therapists.
I’m not here to make any judgments around the use of substances.
Contained below, I seek to share knowledge, experience and advice for Occupational Therapists, who may be in a position to support people with needs arising from their use of substances - regardless of practice setting, as addiction does not discriminate.
Defining the problem
Substance use remains ubiquitous throughout society, deeply embedded in culture and social norms. The unintended consequences (addiction and dependency) continue to present a significant and pressing public health concern. They have a ripple effect - not just for the individual, but those around them - in the form of relationship breakdown, loss of employment and housing, poorer physical and mental health outcomes, premature death and contact with the criminal justice system (UK Gov, 2017). Consider the occupational impacts within even just one of these areas...
It is estimated that, in England alone, there are over 600,00 dependent drinkers - and only 18% of them are currently in treatment (Alcohol Change UK, 2021).
Think about waking up every day, needing a drink of alcohol just to feel well enough to function and to alleviate withdrawal symptoms.
There are a great deal more 'harmful and hazardous drinkers'. In England alone, there were nearly 8,000 alcohol-specific deaths, over 20,000 alcohol-related deaths and nearly 350,000 alcohol-specific hospital admissions in 2021 (UK Gov, 2023). There are approximately 276,000 adults in treatment each year (UK Gov, 2021) across all substances. The UK Government estimates the total socioeconomic cost of alcohol-related harms to society totals £21.5 billion. The use of illicit substances is thought to cost society around £10.7 billion (UK Gov, 2018). Cannabis remains the most commonly used substance in the UK, used by around 7.4% of 16-59 year-olds (DrugWise, 2023).
See the person, hear their story
We are all familiar with the term 'stigma', a horrible concept for bringing shame, not just to what you do, but to who you are as a person. High levels of stigma have been shown to be a barrier to seeking help and treatment (WHO, 2001). You may have heard the myth about someone needing to hit 'rock bottom' before they are ready to make changes. We wouldn't apply this to any other forms of health and social care, so why substance use? What we know is that individuals seek treatment when their personal capacity and resources to manage their problems have been utterly exhausted. This is often reflected in the many and complex challenges someone may have when they do finally enter treatment.
But what actually is stigma?
What makes something more stigmatised than something else?
Why are there levels of stigma?
Amehdani's (2011) study of stigma in mental health sheds light on these questions. The perceptions of how dangerous, unpredictable or strange something seems; perceptions of whether you should be able to control what you do, or be able to sort it out ("you're not trying hard enough!"); the visibility of symptoms makes something more stigmatising; how disruptive a condition or behaviour is in society and whether you can realistically recover, or you’re deserving of 'pity'. It is easily seen how someone injecting heroin is more stigmatised than a dependent drinker, despite both potentially responding to past traumas.
So how can we challenge the stigma associated with substance use, beyond just changing our words and awkwardly correcting our colleagues during meetings? We can have an impact by directly challenging the self (or internalised) stigma of those who use services. We can educate individuals around the effects of substance use and the addiction process on the brain. We can focus specifically around the effects on executive functioning and how this will influence thoughts, feelings and behaviours.
Relapse, whilst always distressing, is a natural part of the process of recovery. Attempts should be made to frame it as such - and plan in advance, to reduce both the physical and psychological harms this can cause.
We wouldn't be occupational therapists if we did not also consider the social environment. By association, stigma can also be a barrier for those we support and those closest to them. We can extend this education and knowledge to family and carers - in an attempt to modify the social environment around the individual, into something more supportive of recovery and occupational participation.
Another way occupational therapists can challenge stigma with more than just words is by applying the 'occupational perspective' to addiction. We have our models of practice (I use MOHO), we view things holistically, we have many frames of reference and specialities (sensory integration anyone?) We have deep and meaningful ways of understanding the link between participation in occupation and health, our sense of identity, connection and belonging. It is often too easy to label someone as 'not motivated' or 'not ready'. We can apply our occupational lens to highlight unseen occupational needs (that might present as a barrier to treatment) and seek to resolve them. High levels of distress from internalised stigma are known to be a predictor for someone disengaging from treatment, so we should make this a priority.
The narratives around recovery can seem all too narrow at times. Morris and Cox (2022) highlight the lack of available narratives for those recovering from alcohol use disorder, limited to the disease model of 'alcoholism' or positive new sobriety. They argue that these don't capture the wide range of motivations and narratives around drinking. As occupational therapists, we can play our part in helping to diversify the narratives around recovery. Someone may be more receptive in recognising they have a problematic relationship with alcohol or drugs if focusing on the nuanced occupational impacts, rather than calculating their weekly units. And of course, participation in occupations has its role to play in helping someone moderate their use of substances during their recovery, if abstinence isn’t the intended goal.
Many of us were drawn to the profession due to our connection with the wonderful values, philosophy and ethos of Occupational Therapy. Naturally, we are going to validate our service users' experiences on multiple levels. Our intentional relationship - and curiosity for what makes an individual who they are - is an integral part of therapy, which nurtures the essence of change. Having worked alongside some amazing peer mentors, nothing can ever replicate their knowledge from experience, the validation or presence of which quells the shame those entering treatment feel. If you haven’t already, connect with your local peer mentors, or lived-with and living-experience advocates.
The 'occupational perspective' of addiction and dependency
The occupational perspective on addiction and dependency may seem a recent focus, further brought into the light by Twinley's umbrella concept, 'the dark side of occupation' (2020). So very much has been written about the role of occupational therapy in substance use, exploring the concept of 'addiction as occupation' (Guyonnet, Stewart and David, 2023; Dogu and Ozkan, 2023; Ryan and Boland, 2021; Rojo-Mota, Pedero-Perez and Huertas-Hoyas, 2017; Wasmuth, Crabtree and Scott, 2014). It is already in the light and we have the tools and knowledge to understand and address it. We just need to be talking about it more and integrating it into training, so that any therapist, regardless of setting, feels confident to explore and intervene.
Exploring the phenomenon of addiction, it is clear that in order to support someone in recovery, it takes more than replacing the occupations like-for-like (Wasmuth, Crabtree and Scott, 2014). Opportunities to engage in new occupations geared specifically towards reshaping social lives, identities, roles and routines are required. In Wasmuth, Brandon-Freidman and Olesek's conceptualisation (2016), they found that individuals experienced a lack of purpose, direction or occupations to organise their daily life; they experienced a complete 'breakdown of self', posing serious threats to their mental health.
By acknowledging addiction as an occupation and then focusing on this occupation's gains and harms, occupational therapists may be in a position to gain trust of clients and help them make adjustments to their occupational lives, that are personally beneficial (Wasmith, Crabtree and Scott, 2014).
Helping to bring forth personal realisation of the benefits of using substances can sometimes pose a challenge to therapists. To be truly person-centred, we recognise that service users have hopes and aspirations beyond the cessation of substance use.
Often the hope is that, by providing other opportunities to experience a genuine sense of self - connection with others, learning alternative methods for regulating emotions, having someone to help you see things differently - the use of substances will become less appealing.
Occupational therapy interventions for substance use disorder
The evidence for what occupational therapists are doing to meet the needs of those using substances is laid clear in Ryan and Boland's (2021) scoping review of interventions for people with substance use disorder. They organised interventions into three themes:
Single occupation-focused interventions
Skills training, including daily living and vocational
Establishing community-based sober routines
They highlighted that creativity was a strong element of practice and that the neurological process of addiction should inform treatment approaches. Work is a critical component of recovery; occupational task engagement and achievement was important in building self-esteem, restoring self-concept and routines. They described a 'chain reaction' when service users are supported to make one influential positive chance, dispersing to other areas of life.
Wasmuth, Outcult and Buck (2015) described the unique contribution of occupational therapy to this setting was to foster a sense of 'mastery'; pulling together all the skills, knowledge, courses and interventions service users had received - and structuring them into real-life situations, related to occupational participation. A great deal of occupation-based intervention is already offered in substance use services, just not by occupational therapists!
The occupational challenges of those in early recovery are best described by Kitzinger et al's (2023) exploratory study of habits and routines...
'Individuals have engaged a great deal of time in obtaining substances, using substances and recovering from their effects. Thereby limiting or eliminating certain occupations, or valued daily activities.'
They isolated challenges to sustaining recovery, arising from:
stigma
anhedonia [inability to experience pleasure, often from activities one used to enjoy]
sleep disturbances
mental health co-morbidities
negative social support networks
Their study found that the most difficult time of day related to patterns of unused time. When there was a lack of structure, or unoccupied time, individuals returned to previously established positive supports.
Yeah, but it’s still a choice to continue using, right?
A systematic review of relapse factors in alcohol use disorder from the past 20 years (Sliedretch et al, 2020), framed around the bio-psycho-social-spiritual model, found a number of trends which may light the way for occupational therapy interventions. The review found that contributory biological factors to relapse included poor physical health and difficulties with sleep, amongst others. Psychological factors contributing to relapse included the presence of co-occurring mental health issues, emotional dysregulation and life events associated with psychological trauma. Unsurprisingly, low quality social support was highlighted in the social factors.
Concluding with the spiritual, they found that spiritual beliefs and practices were protective (think Alcoholics Anonymous) - but incorporated a broad definition of spirituality to include the perception of life 'purpose'. Having a purpose in life, doing meaningful things, in meaningful roles, having a sense of identity and connection. If this doesn't scream occupational therapy then I don't know what does? Occupational therapy has been shown to be effective in promoting self-management of aforementioned physical and mental health conditions (Bevan Commission, 2021; RCOT, 2018).
In order to alleviate the losses felt in early recovery (which are often associated with relapse), priority should be given to developing new patterns of occupation - in the form of roles, routines and connections that are congruent with the construction of newfound occupational identities (Vegereis and Brookes, 2022).
Owing to the distressing nature of addiction and dependency, one can easily be drawn to the behavioural or social impacts. This draws attention from the neurological aspects of addiction. In an article written for occupational therapists, Gutman (2006) outlines the process of addiction and how individuals are neurologically primed to relapse from changes in the brain. Therapists can intervene to challenge distorted thinking that has arisen from these changes, supporting relapse prevention by modifying responses to drug-related sensory stimuli.
Evidence shows that substances have an impact on different executive functions and can persist beyond cessation (Canales et al, 2022; Maharjan et al, 2022; Valdes and Lunsford, 2021). Executive functioning (or cognitive process skills) involves using self-control to facilitate goal-directed behaviour, manipulating current information in working memory, and shifting between different tasks or cognitive states (Miyake et al., 2000). It falls within our professional domain to understand the implications of this on occupation. We have the core skills and knowledge to identify and intervene in these challenges - such as via activity analysis, environmental adaptation, grading, problem solving and the therapeutic use of occupation (RCOT, 2019).
Drawing specific attention to Alcohol Related Brain Damage (ARBD) or Alcohol Related Cognitive Impairment (ARCI): You may have heard of 'alcohol dementia', Wernicks-Korsakoff syndrome or other variations; ARBD is the umbrella term. As a profession, we have a great deal to offer those experiencing this life-altering (but potentially reversible) condition (ARBD Network, 2023). ARBD has a pronounced effect on executive function, that impacts on one’s ability to successfully participate in all occupational domains over time.
As occupational therapists, we support the (re)engagement in occupations, that provide a meaningful alternative or moderating influence on alcohol consumption. We can support and educate carers to modify the social environment and grade occupations accordingly. We can provide evidence and guidance around potential care arrangements, or placements to support individuals to live more meaningful and independent lives.
To put it briefly
The strength and value of occupational therapy presence in substance use services comes from our understanding of the effects of conditions on occupational participation. Our core skills help to elucidate the challenges, and to formulate interventions to protect or restore participation in meaningful occupations.
No other profession in this field does what we do. We are principally concerned with the connection between occupation and health, which becomes more nuanced and complex with substance use. Through being better informed about the impacts of addiction on the mind - and the pervasive effects of stigma - we might better equip ourselves to support individuals to be the agents of their own change.
About the author
Jon Fisher is an Occupational Therapist working in Aneurin Bevan Specialist Drug and Alcohol Service (ABSDAS) in South Wales, UK. Jon accrued years of experience working in substance use services around the UK prior to training as an Occupational Therapist; he worked in various mental health roles, before combining his knowledge, skills and experience to develop the new role in Aneurin Bevan UHB.
Jon is facilitator for the UK and Ireland’s 'Occupational Therapy and Substance Use Network'. The professional network brings together occupational therapy colleagues from around the UK and Ireland for practice support, sharing of knowledge and resources and to pursue the development of evidence and recognition with the RCOT.
For responses or further information, contact Jon:
via email - jonathan.fisher2@wales.nhs.uk
or via X (formerly Twitter) - @Fisheraddiction.
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