Normalization for whom Normalization for whom? Tim Rapley Health Technologies and Human Relations Research Group

On today’s menu Alcohol interventions History Screening and Brief Interventions Normalization for whom? Researchers ~ normalised, adopted, rejected Funders, policy makers, and some providers ~ adopted Front line health practitioners ~ rejected Patients ~ normalised, adopted, rejected

The multiple lives of complex interventions? CIs embedded in interactional, organizational and social milieus Stable, pre-given, entities. Ideation, mobilisation, enaction and then normalization (May et al 2003) Medicines not medicine Organizational, professional, spatial, temporal distribution Multiple social worlds, epistemic frames, lifeworlds, praxio-ontologies.

The medicalisation of drunkenness At the beginning of the last century [19th], medicine and alcohol where drawn together to construct a new category of persons, which by the 1850s had acquired the label ‘alcoholic’ … In Britain … drunkenness ceased to be one of a number of normative states experienced by large sections of the population, and became a ‘problem’ that was opened up for reasoned dissection (May 1997: 170-171)

The normalization of alcohol interventions Habitual drunkenness ‘Horrid and Beastly Sin’ (Anonymous 1705) ‘disease of the mind.’ (Trotter 1804) ‘palsy of the will’ (Rush 1812) Disease of will Alcoholism Disease of motivation Alcohol disorders, problems and risky drinking

Phil Strong’s theory of endogenous normalisation? [A]lcoholics break three broad principles which shape conventional medical practice: the assumption of medical expertise; the belief that medical matters fall largely within the ‘natural’ sphere of things; and the assumption that, despite doctors’ inability to intervene or order, patients are normally motivated to comply with medical instructions. To break one principle would make matters difficult enough, but to break all three renders normal consultations highly problematic’ (1980: 24)

Re-medicalisation (and attempts at normalisation) The ‘lack’ of alcohol intervention Normalization, adoption and rejection Ignorance, prejudice and inability? Rational, practical, reasons? More education Technical problem of practice New theory, new model, new complex intervention

Re-medicalisation (and attempts at normalisation) Alcohol is a global problem Primary prevention should be supplemented by secondary prevention Primary Health Care is well placed to take the lead in providing secondary prevention.

Remedicalisation (and attempts at normalisation) Individuals and populations are at risk from alcohol-related problems. Drinkers should be screened and those at risk or risky should be given appropriate interventions. Appropriate interventions should be centred on changing the risky behaviours of drinkers (Source: Babor, Ritson, and Hodgeson 1986)

Remedicalisation (and attempts at normalisation) Sections of research community engaged in ideation, mobilisation and enactment Manifesto outlines a new problem – ‘spectrum of alcohol problems’ with a new solution – ‘screening and brief interventions’ Manifesto for normalization

Remedicalisation (and attempts at normalisation) Having described the diversity and at times cultural specificity of alcohol problems and the wide range of socio-medical agencies who encounter these problems, it will become apparent why we have chosen the primary health care setting as the focus of the remaining discussion. The main reason for the choice is the need to start with a model which can be translated relatively easily to a variety of settings and cultural groups. [My emphasis]

Remedicalisation (and attempts at normalisation) Connects to issues important for those in this setting as alcohol problems are a significant source of mortality, morbidity and family problems. A low cost solution as it ‘does not require a cadre of alcohol specialists but relies principally on the skills of individuals who are already in post and accessible to the population they serve’ It enables easy replication of effective interventions as the settings are similar.

Remedicalisation (and attempts at normalisation) De-normalization of CI around alcoholism Normalization of CI for alcohol disorders, problems and risky drinking (SBI) For research community For public health messages For leading sponsors and funders

Normalization for the research community 361 controlled trials for the treatment for alcohol use disorders 72 502 ‘clients’ Brief interventions and motivational enhancements had highest ‘cumulative evidence scores’

Practitioners rejection? Recent outcome evaluation studies have provided compelling evidence that brief intervention in primary health care settings will facilitate significant reductions in hazardous drinking. Despite this evidence most general practitioners either do not discuss drinking with their patients or only respond to obvious signs of major dependency [emphasis added] (Adams et al. 1997) Unwilling or unable to implement a technical solution Still a technical problem of practice

Practitioners rejection? ‘Efficacy trials’ Normalization of CI for SBI Practitioners, patients, researchers and sponsors ‘Everyday practice’ Rejection of CI for SBI

The lives of SBI Normalization from sections of research community Dissent, rejection and adoption Adoption from funders, policy makers and some providers Rejection from professional bodies Rejection from front line health practitioners Proxy rejection from patients Normalization, adoption and rejection from press, general public and patients

Carl’s question How do we know when SBI is normalized? When it is invisible, routine, seen but unnoticed, ready to hand, goes unsaid, assumed When it is generates QOF points.