Producing “Progress” Through the Implementation of Outcome Monitoring in Alcohol and Other Drug Treatment

Abstract

Outcome monitoring-a process in which clinicians use standardized tools to routinely measure client ''progress'' on predefined outcomes of interest over time-is increasingly being implemented in alcohol and other drug (AOD) treatment services as a way of demonstrating quality of care. However, relatively little is known about the implications and unintended consequences of implementing outcome monitoring in clinical and social practices. In this paper we draw on qualitative data emerging from focus groups with clinicians who piloted an outcome monitoring tool in Melbourne, Australia, using conceptual tools drawn from science and technology studies. Rather than acting as a stable empirical object, we argue that realities of progress are enacted multiply in relation to preexisting treatment discourses and policy, organizational practices of data collection and management, reporting tools, and clinician attitudes and practices. In particular, we trace how the tool orders the ''problem'' of drugs differently to the qualitative mode of ordering; how different modes of ordering progress hang together and the tensions and coordination strategies that are involved. And finally, we highlight an unintended consequence of the outcome monitoring process-the enactment of vulnerability and its distribution across the clinical relationship. We suggest that researchers, policy makers, and clinicians need to think reflectively and critically about the ways in which we and our tools and interventions are influential in producing AOD problems, what constitutes progress, and ultimately what the focus of treatment should be.

Making visible the politics and ethics of alcohol policy research

“…Why specific phenomena come to be defined as problems, the crucial role of research and policy in constituting these problems (rather than responding to pre‐existing problems), and the ways in which these problematizations make visible and possible certain solutions but foreclose others, are all questions that similarly occupied Gusfield. Other recent critical work , animated by theoretical developments in science and technology studies and feminist science studies (e.g. by Donna Haraway, a trained ethologist , and Karen Barad, a trained physicist ), similarly draws attention to the politics and ethics of AOD research and policy, and the implication of supposedly objective science in these political and ethical processes.…”

An argument against the implementation of an ‘overarching universal addiction model’ in alcohol and other drug treatment

“…Firstly, even if implementing an ‘overarching universal addiction model’ was considered to be a good idea (which we do not think it is) or even possible (given the heterogeneity of presenting concerns and aetiological pathways), it is unlikely to be realised in practice in the way policymakers might intend. As has been consistently noted , the translation of seemingly well‐defined and ‘simple’ interventions or tools, let alone arguably more abstract ‘models’, into practice is not simple or straightforward. Unlike the controlled conditions in which interventions are tested, the world of practice is always messy and complex.…”

“…Unlike the controlled conditions in which interventions are tested, the world of practice is always messy and complex. Any intervention or tool interacts with a whole bundle of moving parts, processes, technologies, values, organisational philosophies, knowledge, structures, norms and clinical practices . As it encounters this messy bundle of moving parts, the intervention that emerges in practice is often very different to what the researchers might have imagined .…”

“…Any intervention or tool interacts with a whole bundle of moving parts, processes, technologies, values, organisational philosophies, knowledge, structures, norms and clinical practices . As it encounters this messy bundle of moving parts, the intervention that emerges in practice is often very different to what the researchers might have imagined . As such, there is no reason to think that an overarching universal addiction model would somehow be immune to the complexity of implementation and practice.…”

“…Similarly, treatment providers can (and often do) critically reflect on and challenge their own understandings and beliefs about addiction and people who use drugs to ensure that these are not shaping how presenting concerns and responses emerge in particular ways . Working with complexity and a variety of models is not easy, but alcohol and other drug treatment providers already routinely negotiate complexity and different needs, models, funding, administrative and therapeutic requirements, and in many cases are quite adept at doing so .…”