In this occasional series in conjunction with the SSA’s journal Addiction, we record the views and personal experiences of people who have especially contributed to the evolution of ideas in the journal’s field of interest. Professor Betsy Thom is the head of the Drug & Alcohol Research Centre at Middlesex University, London. She is a social scientist with a particular interest in policy and the policy process in the alcohol and drug field. She has published widely on a range of alcohol and drug issues, and acted as a consultant on evaluatuons of the European Union Alcohol Strategy. She was Editor-in-Chief of the academic journal Drugs: Education, Prevention and Policy for 20 years.
An audiorecording of the conversation can be found here.
ADDICTION (A): Well, welcome Betsy and we are very pleased that you’ve agreed to do an interview in this series. Maybe you could start by talking about how you became involved, but also about what your career was before you became involved in this area.
Betsy Thom (BT): Okay, I started after university in languages, because that’s what my first degree was and I had various jobs before I did some teaching, language teaching, during which time I studied sociology. Then I went for two years to Vienna and I was working intermittently for a centre there in social welfare training and research, using sociological approaches. When I came back I got an offer of a job from Margot Jeffreys at Bedford College and she was working in medical sociology. So Margot was doing a study of rheumatoid arthritis and referrals between GP and the hospital and when her unit ended, because she retired, I was looking for a job and the first one that appealed to me at all, was a job at the Addiction Centre at the Institute of Psychiatry under Griffith Edwards and that was to do with women and alcohol. It was quite a broad brief that I saw. I didn’t know anything about alcohol, or the Institute, or Griffith Edwards, but I was interested in women’s health issues. It was a big thing at the time, so I thought I would try. I went down there, had an interview with Griffith, Edna Oppenheimer and Margaret Sheehan and Gloria Litman, who were all quite well versed in the area and well known. And I thought Griffith Edwards was charming and I got the job. [Laughs.]
A: Well you must have impressed them. So was that a group of people who had been working on women already?
BT: Not exactly. There was a background to interest in women and alcohol in that unit. Betsy Ettorre obviously was interested in substance use in general and women and treatment and I think she’d written some stuff by then, but I can’t be sure that might have come later. But Margaret Sheehan had been involved with the Camberwell Council on Alcohol in producing a book, which was really quite important in the field, it was called ‘Women and Alcohol,’ published I think in 1980. That was put together by a number of people who had been collaborating with women in the services, mainly women, some men as well, to look at services for women with alcohol problems and how these services were not addressing the issues and to look at how, to what extent gender was important in considering women’s drinking, women’s access to services and the kinds of services that were available for women at the time. So it was quite critical of the field.
A: And who was funding the research for the job that you applied for?
BT: It was just part of the unit’s general…
A: General funding.
BT: And I think it was the Department of Health at the time.
A: Oh right.
BT: Or it might have been the Home Office, or it might have been MRC, but I think it was the Department.
A: So one of those.
BT: Yeah a government or a large funding agency.
A: You’ve said a little bit about what was going on at the time and what had led up to the work, but tell us about the early days, the work that you did in the early days at the unit.
BT: Well that was the first project looking at women and alcohol and I came in with quite a lot of idealistic ideas about what I wanted to do, particularly focus on women and have nothing to do with men. But I was dissuaded shall we say about that, so I had to include men in the study.
A: Who dissuaded you?
BT: It was Griffith of course.
A: Oh yes.
BT: He didn’t interfere much, but he just had a way of getting what he wanted I suppose. Anyway I did include men and in the end I was quite grateful because it did add considerably to the ideas and to the notion of looking at gender and as women and gender, rather than women alone. A little later, quite a bit later, it never had the same emphasis, but attention did turn to men’s use of substances and masculinity and I wasn’t much involved in that. But at least I was marginally there and knew where it was coming from and I think it was important. So I was able to talk about both and that was good.
A: And I guess there weren’t that many people working in that sort of area at the time were there?
BT: Very few. Moira Plant in Scotland was the only one I think that I can remember and she was quite well-known, she’d looked particularly at foetal alcohol syndrome and had a work out on that. And that was again one of the aspects of the discussion that was going on at the time. I think he was called Astor Balfour Sclare no, anyway there was somebody who was attached vaguely to the unit and published in Women and Alcohol who was also writing very sensibly about foetal alcohol syndrome and drinking, a really good paper. And of course that again has become a lively topic.
A: In more recent times, yes it’s come back onto the agenda.
A: So you published in that area.
BT: I published some papers on women’s help seeking basically. Then the funding for that part of the work ended and it wasn’t a well-funded area of work anyway, so subsequent to that I wasn’t able to do much that was funded, bits and pieces, chapters for books and that kind of thing.
A: But the work went on with other people.
BT: The work went on, slowly and again with a gap I think, but more recently the past five, six years there’s been a few more people coming into that. Patsy Staddon in alcohol, Natasha Du Rose was in drugs, two that I am aware of and there were people like Jan Waterson working throughout that period. So there was a steady little trickle of people involved and interested in the issues, yeah and keeping it alive.
A: And I think you comment there was a good sort of alliance between women researchers and people running services, research feeding into policy making or service decisions.
BT: Certainly research and practice feeding into each other and good collaboration. I think the link to policy was less good, because I’m not aware of how it, at that time, it fed into policy, if it did. It was marginal. But certainly the link with practice was very strong and a lot of the ideas were coming out of practice as well.
A: So in a way it’s a model of what people are trying to achieve later on.
BT: I think so, yes.
A: Tell us about what your next area of work was.
BT: Well the next area of work was just given to me, Griffith came in one day and thought that I should be looking at general practitioners management of alcohol. So I thought okay why not, if that’s going to keep me in a job, I’ll do it. Again not something I knew anything about. But after digging about a bit I found a paper by Phil Strong and he had done some work in that field, looking at what GPs had said about dealing with people with alcohol problems, which they considered to be ‘dirty business’ in his words, not mine. I discovered that unfortunately after I started the project and I was working with the registrar called Carlos Tellez, on interviewing general practitioners and asking them about how they viewed people with alcohol problems, what they felt they could do for them and all that sort of thing. And of course we came up with the ideas which were well-known that they didn’t want to deal with them, they didn’t know what to do with them and if they did identify there was no help, no services that they could offer. That wasn’t new, we did know that and people like Stan Shaw and Alan Cartwright had done some work looking at what they called therapeutic commitment. They had tried to measure the extent to which GPs felt they had role security, role adequacy, feeling that they were able to do it and were supported and that patients would accept what they did, so there had been work looking at that already and ours kind of fitted into that, supported what was coming out that GPs didn’t feel that they had support or the relevant knowledge and experience and so on. And after that I think a few people in the unit, Colin Drummond was one of them, Michael Farrell I think, with a little bit of input from me, developed an alcohol problems questionnaire, which was meant to identify alcohol problems and could be used by GPs, although I think it was more used in hospitals. So again the GP work was a sort of one off, but of course it came, that as well came back later and it’s very strong now with things like digital approaches to getting GPs involved in IBA, identification and brief advice. So that whole area is now quite lively.
A: And presumably other people, other researchers also developed some of the ideas and the work that you did even then.
BT: Oh yes. Well not necessarily leading from our work, but Paul Wallace, Nick Heather, those people were already, or very soon after began working with GPs as well, to develop tools as well for identification and brief advice and the audit questionnaire from WHO came in.
BT: So they were developing those sorts of approaches, a bit after that study I think, but independently. I wasn’t involved in that.
A: No. But you went on working in this, well not with GPs, but the identification of alcohol issues in groups of patients didn’t you?
BT: Yep. The next thing I did was working with Ray Hodgson on the FAST questionnaire and that came out of some work that I was doing in hospital emergency departments, with people like Robin Touquet, who was very keen on identifying alcohol problems in the patients coming into A&E. So we developed a questionnaire and we went in and we tried to get to measure and see just the extent and prevalence of alcohol in the patients coming in. Then we set up a project to try and get consultants and registrars to do that, to identify and give some brief advice. It was quite a struggle. We were on the research side, Robin was trying to lead the practical side and get it done and he used to have a little league table up on his board of who had got so many in a week and awarded a box of chocolates and so on. So that was really nice, but it was hard, it wasn’t easy to get the consultants to do that for many reasons. So we were working on that and out of the collection of data that we collected, Ray used that and some that he’d been collecting in Wales, to have sufficient numbers, to develop a short questionnaire, because they felt that the AUDIT was too long to be used in the hospital setting. They wanted something specific for hospitals and that’s how the FAST came about and I think it’s quite well used. It still is used.
A: So it is fast!
BT: Yes it’s four questions so it’s very small.
BT: So it’s based on the AUDIT, so that was the gold standard and then all the reliability tests and all that were done with the AUDIT as the gold standard.
A: And so really this is part of a shift in the field isn’t it, away from a specific focus on alcoholics towards a more general population approach.
BT: Yeah definitely. I mean the population approach has strengthened the move that had already started to take alcohol problems out of hospitals, particularly inpatient, move them to outpatient and then moving them into counselling and voluntary services in the community. Then broadening it out even further to look at people who were not dependent, but were likely to have problems that they might be aware of, or even might not be and who were at risk of dependency. So the early intervention shift began, was, along with the population move and that includes now looking at whether identification and brief advice can be implanted and embedded, not just in the medical and the clinical professions, but in other practice such as social work. We’ve even done a study where we looked at housing officers and could they use it in some way, obviously youth work and so on. So it has broadened out tremendously, probation is another biggy under the SIPS project. [The SIPS alcohol screening and brief intervention (ASBI) research programme was funded by the UK Department of Health in 2006 as part of the national Alcohol Harm Reduction Strategy for England. The programme comprised three cluster randomised controlled trials of different methods of screening and brief intervention across three settings: Primary Health Care, Emergency Departments, and Probation Services.] So it really is kind of flavour of the month in a way. So these lines have developed it’s quite interesting.
A: So does that more or less cover the work that you did at the Addiction Research Unit?
BT: It covers that and it actually runs right up after the Addiction Unit.
A: Yes into other things.
BT: Because the A&E work was when I was with Gerry Stimson at Imperial College and then some of the other work at Middlesex, the IBA work has been at Middlesex. But yes that does, because the two main things were women and alcohol and general practice and then of course I started looking at the history of alcohol.
A: So let’s come onto that then. So your move after the ARU was here, well not here, but the main building, Keppel Street.
BT: Yes in the main building that’s right and that happened because I met you on the tube I think.
A: On the Thameslink.
BT: On the Thameslink. And I happened to say I wanted to do a PhD and I had this vague idea and you said oh you were interested and suggested alcohol treatment policy, a topic which had come out of the history of the Society for the Study of Addiction and so I thought oh okay why not, so that is how that got off the ground basically. And you got some money from the ESRC to fund it and it was two years that we got funding for, but the two years got a bit interrupted by a bit of teaching for Gill Walt and then you shoved a piece of paper in my face one day and said, I suppose I ought to show you this and it was for the job for Gerry’s. So I got that job and left after I think a year and a half.
A: Tell us a bit about here first of all before we go onto Gerry’s. So you came here to do the history of…
BT: I came here and I was interested in history anyway, but didn’t have a proper historical background. So this was very good in that it gave me a bit of a feel for historical work and the kind of ways in which you locate current policy and practice within a historical perspective. So that was really valuable and I like to think that I’ve continued to use that as far as one can, because I do think it’s very important in looking at current policy and practice.
A: Well I’m not going to disagree with you there.
BT: No you wouldn’t, would you. [Laughs.] But I was very open to it from the start and it confirmed what I thought and really I’m very pleased I did that. Another thing that really benefitted me from being here was saying yes to Gill Walt to help her with one of her modules and you kind of think sometimes these things, oh it’s a pain, but I ought to do it, but it really paid off, because again I was interested in policy studies because part of my sociology degree had been political sociology. But this was a different slant on it. So I read a whole lot of stuff that I wouldn’t have read and hadn’t read before about the policy process and I’ve been using that ever since. So that was really good, it was an intensive year and a half.
A: What happened as well is you used archives and you interviewed people many of whom are not around anymore.
BT: That’s right. That was absolutely fascinating and I found the interviews with people who had been involved early on in the field, really very exciting and interesting. It filled it in. It indicates the value I think of narrative oral history and I want to do a bit more of that, but nobody funds it.
BT: But that was really good and you’re right that these people have passed on. I’ve still got the tapes, but those old tapes you know, I’ve still got them in a box somewhere. I don’t know how good they are, I would probably look at them now and say, ‘oh my god, why did I ask that or why didn’t I ask lots of things. ‘
A: But it also led to another publications didn’t it, to your book [Dealing with Drink: Alcohol and Social Policy. From Treatment to Management. (1999)]
BT: Yeah there was a book and then there was the one on the units,
A: Oh yeah. But the book was the main product.
BT: The book was the main output.
A: And that’s still widely cited.
BT: Interesting, because I didn’t even know anyone had even noticed it. Once something is done I tend to just let it go, but you said to me, oh do you know there’s a whole discussion going on in the KBS [Kettil Bruun Society] network about your book. I missed the whole thing, I didn’t know. It’s the kind of work I like to do, but as I said you don’t really get much opportunity to do that.
A: The opportunity, no, not with funding.
BT: Particularly now because the shift has been of course to epidemiology, modelling or RCTs and so on.
A: Okay well we can come onto that. So you were here for a year and a half and then I showed you this job to apply for.
BT: Wonderful job.
A: And you got it.
BT: I got that.
A: And you moved, so tell us about that.
BT: I had been a teacher before, so teaching wasn’t new to me, but the main job at Gerry [Stimson]’s Centre for Drugs and Health Behaviour was to set up a new diploma in drug and alcohol studies. It was a certificate and diploma at the time, accompanied with some training days for professionals out there. Now I’ve never developed a whole diploma course before, ever, but of course I’m very good at pretending I know what to do. So anyway, I had to work in collaboration with Clive Tobutt from Thames Valley University. It might be called something else now. Thames Valley University, he was from there and they were a new university, which it was also new to me and they worked on an entirely different way of setting up courses, programmes, developing things, which I thought was completely crazy. You know you have to develop learning outcomes, have all your things that you’re going to read put down every single item for each lesson spelled out, all of that. Anyway I had to do all of that sort of, reluctantly. Then we got this diploma course going. But we had to start it before I’d done all of that, because the time, I had three months I think to set it up and to get it going and we did, we did it and we were developing the programme as we went along. It was quite successful actually and again it was focused on practitioners and we did get practitioners from a wide range of types of services coming in. They were lively, they fed into ideas beautifully, again it was one of these things and I thought it was a good programme. It lasted for several years, even after I’d left Gerry’s. And we went on from that to develop a distance learning MSc which was funded by London University, external department. So I had to develop materials for that. So the period there I think was indicative of a little bit of a surge in training and in looking to accredited academic training as a way of workforce development, because they didn’t use the words workforce development I don’t think, but that was what it was, what does this new workforce need, because the voluntary sector, the community based services and so on were growing, whereas the psychiatric based services, the traditional psychiatrist, clinical psychologist seemed to be waning a bit even then.
A: Even then?
BT: I think, yes. Hence this push to train up the broader workforce that were coming into the field.
A: So that was quite a level of training you envisaged then wasn’t it.
BT: Yes it was. But there was the other level as well with the, what were they called, DANOS and so on, that was going on. I’m not sure if it was exactly the same time, but if not, soon after. So there was a huge push there I think and that course lasted for a while, but I moved on.
A: And what happened to the course?
BT: It continued for quite a long time under Christine Franey and then they developed an MSc in Public Health and that was just being developed or thought of when I left and eventually the drugs and alcohol one folded. I think as well that’s indicative of what’s been happening in the field with other courses elsewhere, coming up and then collapsing, whereas one or two of them have remained pretty steady. Gillian Tober’s has been running for…
A: At Leeds.
BT: At Leeds and the one in Scotland, at the University of the West of Scotland that’s been running for a very long time and has been very successful and of course the National Addiction Centre has run courses of different types on and off. I don’t know how successful theirs are at the moment.
A: And then you moved to Middlesex and you also developed teaching there as well.
BT: I was doing bits of research along the way as well, I mean I have always balanced the two. But then when I went to Middlesex I had bits and pieces, I was part time to begin with, because I had just decided to leave Imperial, I’d had enough. I wanted a more sociological and policy or humanities context to work in, rather than the medical context and I wanted to work with Susanne McGregor who was there at the time. So that’s why I left and I also just had part time work there and some projects that I brought, which were funded by the Health Education Authority, because they were funding at the time, interesting stuff.
A: What sort of things?
BT: Well they funded, partly funded the work on the A&E work that, the FAST questionnaire.
A: That we’ve talked about.
BT: And they funded us to do some work on young men’s’ drinking and that brought back the old things, so we did that. And they were interested in developing something that WHO was interested in at the time and that was community based, multi-component programmes. So we worked looking at various regions in England at how you could develop partnerships and so on. That was a very hands on action kind of project.
A: This was at Middlesex, or started at Imperial?
BT: Well the link with the Health Education Authority started when I was at Imperial but I took it to Middlesex and most of the work was done when I was at Middlesex. And also we were looking at community projects in Luton, which was separately funded. So that area of work, which I’d actually forgotten about, looking at how you can target communities to run multi-components through partnership mechanisms.
A: So this was the origin of your work on partnerships then?
BT: Exactly, which again, well we worked on together.
BT: Yes and popped up again later and was funded by the AERC [Alcohol Education and Research Council, later to become Alcohol Research UK]. So that started at that period and it was linked very much to people like Harold Holder who was doing these multi-component things in the States and WHO, who was interested in community projects of that type.
A: So you’ve left Imperial, you’ve moved to Middlesex and you’re working on these multi-component programmes.
BT: Yes bits and pieces.
A: And partnerships. So how did the work develop at Middlesex?
BT: Then Susanne got some money, half time I think to develop a distance learning drugs and alcohol, which they’d wanted to do before I came, but there was nobody able to do it really. She was obviously working in the substance misuse field. So I got a little team together at Middlesex and we wrote the materials ourselves this time and we got that going. So that lasted for a few years and again that collapsed, you know just not enough students. Partly because the field keeps changing, the needs keep changing, different types of people come into the field and I think the needs are different and the standard accredited programmes don’t change fast enough, I think, except for those that are so well embedded…
A: They’ve got the luxury of spending time to change.
BT: …they’ve got good teams and they can change,
A: Okay so you are still doing a lot of teaching development then in the new job.
BT: Yes I was at that point.
A: And what else did you do?
BT: Well I was involved, I think it was just by somebody inviting me into European work. I’ve always felt annoyed by the dominance of research thinking and policy influence from the United States. It’s not that they’re not doing good work, but I do feel we should be looking at Europe, so I’ve always wanted to work more in Europe. I got invited to something that was set up by the University of Vienna, a small group of European researchers, to consider, it was a one-off meeting, how you would develop teaching at the higher level and research at European level, with collaboration and that was Irmgard Eisenbach-Stangl from Vienna who led that group and she was keen to keep this going. So we had the initial meeting and then the Finnish Academy of Science I think it’s called funded two more meetings, one in Helsinki and one somewhere else that I’ve forgotten. So we had these three meetings and out of that stemmed a group of researchers and research institutions that I’m still in touch with and still work with. That’s how the European Masters in Drug and Alcohol Studies got started, because we started that and I led that from Middlesex. And Irmgard got money from UNODC for a study of drug consumption in European capital cities. So I was involved with that which was nice and then several of us got involved in the large European studies like ALICE RAP and various other ones. So that was how the European stream of work developed for me within Middlesex, in our topic and how the EMDAS got going as well. EMDAS stands for European Masters in Drug and Alcohol Studies. So we developed that and then it started running and that’s still running.
A: Great. And you also became editor of a journal.
BT: Oh I forgot about that. That was when I was at Gerry’s place.
A: But it transferred over didn’t it.
BT: Yes, because it wasn’t part of Gerry’s unit it just happened that I was there at the time and he actually recommended me to the guy who was the editor at the time, to be on the editorial board. I didn’t know anything about editing. I’d done a few reviews for Addiction and that was about it. But again I thought ooh good that sounds like fun, so I took it on and then the guy who was editing had suddenly to stop and I mean suddenly, boom like that. And the publisher which was Carfax at the time asked me if I would take it over and there were only two or three of us working on it, the other one was Gelisse Bagnall in Scotland, she was also on the board and so I thought oh why not, let’s do that. So I started working on the journal, I kept that for 20 years.
A: How did that develop?
BT: Well I enjoyed doing it, but it was a lot of work obviously. I didn’t really know anything about running a journal, so it was learn as you go along. I think I started to recruit one of two people fairly soon after I took it over, as assistant editors or whatever I called them, I can’t remember. Then Griffith Edwards was setting up something called International Society of Addiction Journal Editors [ISAJE]. That’s what it became known as, but it was just a group to start with and we went to Farmington for the first meeting in the States, where Babor, Tom Babor is and we had this meeting of journal editing. I have to say it was really, really good, because we were able to exchange ideas about the journals, about what we find difficult, about what seemed to work and what wasn’t, about the dilemmas that had come up, you know the things that really were ethically worrying sometimes or difficult to deal with and I found that extremely helpful. That became, I think first of all it was a two yearly meeting, I can’t remember now and we kept in touch and it developed into ISAJE, which is now quite a solid organisation and has developed all sorts of standards and guidelines and things like that for journals to regard or disregard as they like.
A: But when did you give that up, a few years ago?
BT: ISAJE and the journal I gave up, I think about three years ago. I gave the editorship to, the editor in chief to Torsten Kolind from Denmark, who was one of the editors at the time. I had already made co-editors in Middlesex, Rachel Herring and Karen Duke and they’re continuing. So it’s a group of co-editors. I was very keen to keep women as editors because it’s a terribly male dominated area of work, the journals and I think, certainly when I had it there were no other female editors at all, unless there were journals I wasn’t aware of, but I think not. And even now I think there are still rather few women who are editors of addiction journals.
A: Any reason for that do you think?
BT: No just the usual reasons, which I won’t go into. One of my students is actually looking at that, not in the addictions field, in another field.
A: We’ll look forward to that. Right. So and that’s really developed well that journal.
BT: I think the journal has done well, I mean it’s got a small impact factor, but given you know the multiple journals that have sprouted in the field over the period and that’s been another development, then it’s done pretty well I think. And of course the original focus, I think they have preserved this, was European research. We went out deliberately to try and attract European research. It wasn’t that easy and also qualitative, historical, cultural, qualitative types of papers.
A: Which are not areas that are well represented necessarily.
BT: And giving more leeway on the words, which these types of papers need, you know you can’t always do it in 3 to 5000. So that was part of the ethos of that journal.
A: I think you’re still very much involved in European initiatives aren’t you.
BT: [Laughs.] Yes I am. I’m not sure about it anymore. Well we’ve got one which we coordinate, it’s called EPPIC, which Karen Duke’s son came up with, which is very good.
A: What does EPPIC stand for?
BT: Exchanging Prevention practices on Polydrug use among youth In Criminal justice systems. It’s exchanging knowledge and research on prevention, intervention for young people who use drugs and are in some way in touch with the criminal justice system. It’s such a mouthful that none of us would remember the title. But that’s the focus. We started that in January 2017 and it ends in 2019, December, so we are about half way through now. It’s not an easy project to run, because it’s a target group that even practitioners find extremely difficult to engage with and research is finding it extremely difficult to engage with as well. But it’s quite a neglected area in some ways.
A: That’s funded by?
BT: The EU, CHAFEA.
A: Right. So yes one of the questions we’d like your views on is, what sort of changes have taken place in the overall field of studies?
BT: We’ve sort of covered some of that. Clearly the big move I think in policy and practice is the shift to public health, you know, a population view and a public health view of alcohol or substance use in general, all substances. That’s been accompanied by a shift in the research I think, somebody once said that the, it was you maybe, that epidemiology is the bed fellow of public health, was that you? It might have been. I’ve remembered it anyway from ages ago and I think that’s true, along with this shift to a population and public health perspective as the main framework of understanding, I think has gone a shift in the preferred kind of research, to … I mean it always was, I mean there was always a preference for quantitative, but I think that’s become more marked in that epidemiology has become stronger, modelling studies. The RCT is what gets the big funding. Systematic reviews are now the thing. I don’t think I’d ever heard of systematic reviews when I entered the field in the 1980s, I don’t think so. So all of that has happened. The workforce has changed hugely. I’m quite interested in that, because you know as I said earlier when I started it was psychiatry that was quite strong, clinical psychology, social work, nursing, they were all part of it. There were the voluntary services and so on, but they’ve become big now, great big and the smaller voluntary services are being gobbled up is maybe not the right word to use, but absorbed into these large organisations like CGL [Change Grow Live] and so on. So that seems to have been a major trend and in some ways perhaps I think it’s fragmenting things, I don’t anymore know what’s going on in the services. So when we were looking at these young people and prevention approaches, it’s really difficult to get the hang of whose producing what for whom and what kind of things are available for these young people.
A: Bodies like the HEA, HEC that you mentioned are no longer there are they?
BT: That’s right and they had some kind of coordinating role. Alcohol Concern used to be an excellent coordinating body and the drugs one, DrugScope, they used to be a wonderful place, they had the literature, they knew what was going on, they had newsletters, they issued fact sheets, which kept you up to date. None of that is easy to get now.
BT: And there’s loads of websites, but finding your way through them, or finding them, all of that I think makes the field messier.
A: It’s difficult. And education also you mentioned has changed hasn’t it too, education and training.
BT: You mean training and education. I think so. I’m not sure where the things like the DANOS [Drug and Alcohol National Occupational Standards] are now, whether they still exist or not, I haven’t heard of them for a long time.
BT: And then there were some other things that came in. They’re team training manuals and so on that get produced. I don’t know how good they are or how well used they are. The courses come and go on the whole and I don’t know if what is being provided suits the current workforce and the needs of the current workforce. So I think there are problems there. Of course the other big thing is users, you know bringing users into both policy and research and making sure that their voices are heard. And again there’s always a bit of a lip service to that, but not much happening. But now for example most of the research funding bodies want to see that you are including users or the target group in some way, not just as consultants, but in the design, in the execution of the work and so on. And while you can see a lot of good things in that, there’s also a lot of problems in that.
A: What are the problems?
BT: Well the problems that we’ve found in our small attempts to do that is that if your target group are professionals, you try to bring them in fully as collaborators and so on in the research. They find it very difficult to give you the time, so they don’t have time for the research. They change quite rapidly, the people change. You’re working always through gatekeepers to get others in the population and it causes problems. So although there’s advantages, I think people have to look very clearly and discuss the disadvantages as well and you can’t always get people who really know what you’re trying to do in research.
BT: It’s difficult to get people to do interviews which are non-biased for example, if they’re not researchers. So they’ll say things like well as we were talking about you know a couple of months ago, you don’t do that anymore, do you.
A: Yes agree or disagree with.
BT: So there are a lot of issues. But I mean people are aware of that. But that’s been another shift because that’s where I started talking about…
A: The involvement of the user.
BT: There’s a lot of different things going on.
A: So what’s it been like working in this area and what have been the key facilitators and also the key challenges?
BT: I suppose it’s been interesting enough to keep me in it since 1980 whatever it was, yes. [Laughs.] So there’s that to be said for it. I think the really interesting bit of it is that for someone who is not strictly within the clinical side, you’ve got a vast array of possibilities to look at the culture, the history, plus the clinical and the treatment and the therapeutic, plus the policy and that’s what makes it really interesting, because you can dot about between all of that, assuming you can get the money and you’ve got the energy.
A: We’ll talk about the money because obviously funding has been important hasn’t it?
BT: Yes very. Do you want me to talk about that now, because that’s not what you asked me?
A: Yes say something about it.
BT: Okay I suppose I’ve been lucky in being in, some of the time, in well-funded groups or units. I mean the Addiction Centre at the Institute of Psychiatry had five year funding, which was extremely good, you know rolling funding, and as long as they produced a report that was satisfactory, they got another five years. That went on right up until Griffith retired and I’d left by then. Similarly Gerry Stimson had very solid funding over a long period of time. That wasn’t the case once I got into Middlesex. I was lucky in that I got funding for a job, but the research had to be funded by going out there and bidding.
A: For projects.
BT: And I’d always done a little bit of that while in Gerry’s unit, but that became the main thing, the main way of getting money in Middlesex.
A: But you’ve also been involved yourself with funding agencies.
BT: Oh yes, and that’s been really interesting. I mean that’s in a sense been one of the facilitators because I got a lot of knowledge out of that and made a lot of very interesting network connections. So I was involved with the Alcohol Education Research Council for a long time, I can’t remember how long. That started when I was at Imperial College, so it must have been before 2000, so for many years and I saw lots of changes in that. But from my own point of view that was a facilitator because I learned a lot about research, different methods, approaches, what reviewers were looking for, what funders were looking for and how to write proposals better than I was doing at the time. So that was great. And the other one I was involved with was a programme run by the Joseph Rowntree Trust, which was led by Charlie Lloyd, ex-Home Office, but then he went there. And their focus was mainly on drugs at least for the start and then he incorporated alcohol. So being involved with that programme again, new set of people in the drugs field and new types of knowledge, different approaches to research, because the JRF wanted slightly different things, so that was really a very, very good experience. I would recommend that to anybody.
A: And you were their expert advisor on alcohol?
BT: Yes on alcohol, .and that was good. It also, and I have to be honest about this, gave you the opportunity to get attention drawn to topics and issues which you felt were important and were being neglected. So for example I managed to get young people and alcohol, an awareness of that and some ideas flowing about why young people don’t drink. Well that’s become a big topic now.
A: Mm a big issue yes, very much so.
BT: So that was just at the time when there was starting to be a downturn in consumption and we knew from a small study that I’d done with Patterson and oh, Nanchahal … they were people here.
A: Kiran, Kiran Nanchahal.
BT: Kiran and Sam Patterson we’d done a study funded by the AERC on the decline in population drinking, quite a quantitative one using secondary material data. So I knew that there was this decline and I knew that young people were showing up and that was able to feed it in and get some qualitative work going, to try and understand what was happening at the time. It was only one small study and of course there again you can’t continue a line of enquiry because the money runs out, which is really frustrating.
A: So they pump prime but…
BT: Yes but then you can’t get the money to continue, because we were looking at young men, it would have been good to see slightly older men if there was the same trend, what happened when these young men got a bit older, were there other men similar, but who were drinking heavily and why. You could have expanded it in all sorts of interesting ways, but we couldn’t. Then of course this idea of how do you explain the drop in consumption it’s again very interesting.
A: So what have the main challenges been?
BT: Well money obviously is one of them and the frustration of starting on an area of enquiry that you feel is well worth pursuing, but there isn’t further funding. So in order to keep things alive in your university or your unit you’ve got to take funding for whatever is flavour of the month and go with it and that’s what you just have to do. And so that can mean it’s very difficult to keep lines of…
A: Of enquiry open that you consider to be promising.
BT: Yes and interesting let’s say as well, there is that, you’ve got to admit to the personal thing of certain topics interest you and others don’t particularly. It’s just you. And also of course as you develop you’ve got other people dependent on you for their work, so you know in a unit in DARC, that’s the Drug and Alcohol Research Centre, there are people who work there and you want to keep their contracts going, or at least partial contract and then they can teach half-time or whatever. You’ve got to keep money in or it collapses.
A: We haven’t talked about the Drug and Alcohol Research Centre.
BT: No I forgot that.
A: Well tell us something quickly about that.
BT: I started that as a Drug and Alcohol Research Group fairly early on in Middlesex and tried to grow it and it did grow and now it’s a University Centre. It mainly though consists of people who are teaching as well and their main role is teaching, they have to teach, but they want to do research in this area. We work across Schools, so we have cross disciplinary work going on from the criminologists are a big factor and within health, all the social sciences and health faculties collaborate and we’ve even got a few people in the Business School. So they come and go as people can, they drop in or drop out of the work, depending on what’s being funded and what their role is and what they can do. But we’ve managed to keep it going, to get funding and to have projects since around 2002/3 I think.
A: A long time. So tell us who’s been the greatest influence on you and in what way?
BT: Well I’ve never been one for having individuals as mentors. So I’ll sort of side-step that one and say units and contexts and I’ve spoken about them. I think all the units that I’ve worked in and thereby the people in them, because obviously the units are the people, have had a distinct influence. I mean for example from Griffith Edwards I learned that you have to stand up and give a talk from notes on a postage stamp. [Laughs.] And I learnt that pretty quickly.
A: And practice it first.
BT: Yes exactly, yes. So from everybody you learn something and I think the biggest learning in a way is how to work in a group and I think that’s valuable too, because you need to compromise you need to look to the needs of everybody in your group, you know and try to, everybody develop each other in some way. So that’s good. So each of the units has and as I said places like AERC and the Joseph Rowntree that I think have a huge influence.
A: And presumably also your European work?
BT: And the European network where you get different perspectives coming in and people challenging, you know oh that’s just how Middlesex does it, you know do you always have to bring in how Middlesex does it. [Laughs.]
A: You’ve mentioned AERC, Alcohol Research UK now and Joseph Rowntree but you’ve also been, weren’t you an advisor on a House of Lords committee as well?
BT: I wouldn’t say they influenced me.
A: No. But sometimes the influence goes another way doesn’t it?
BT: I don’t think so. I think that report fell very much into a black hole because it was just at the time when the European alcohol strategy was ending you know and they haven’t renewed it. So there are still things going on, but I don’t know if the report had any influence.
A: It was a report on European strategy?
BT: On the strategy and whether it should continue and what the advantages/disadvantages were, had it achieved anything that kind of thing and clearly as a Europhile I wanted to be part of all of that as well and still do. But yes I did do that and I’ve been consultant on other things, UN stuff, but that’s long ago.
A: So where do you see the field going now and where would you like it to go?
BT: I hate to think. I don’t know, I’m certain, I’m not sure how far I ought to make this public actually. I’m pretty fed up with the public health approach. [Laughs.]
A: What do you mean by the public health approach?
BT: The whole population. I think it’s quite healthy to look and say yes everybody has to think about their health and to give the public advice, I have no problems with that. I have a problem with the standardisation of everything, with the simplification of everything, i.e. the public have to have simple messages. I don’t like that. This is a very personal point of view. I think the public health approach is supposed to be evidence based, but it isn’t always evidence based and there is a tension between the messages that they feel they should be giving the public and their desire to be evidence based. I think there’s a tension there. We are running a conference on that, oh you know about it, because Alex is talking. In November, about how research is translated into public health messages to the public.
A: Oh yes.
BT: So there’s that and some public health advocates take an approach which is rather extreme. They think we’ve got the evidence, we’ve just got to apply it and they don’t want to look critically at the evidence, because evidence is never static in my view. So that’s not what you asked me, you asked me where is it going.
A: Do you see more of that happening then?
BT: Yes I do because it appears to be the right way to go. It fits money issues in a way, because it’s responsibilising the public. The rise of digital health is probably linked because there is a lot of things going on to do with for example digital IBA identification and brief advice in the alcohol field and using digital means for counselling and feedback and all that sort of stuff, if not alone, in conjunction with the face to face work. So there’s all of that going on.
A: So you see a kind of identikit approach emerging?
BT: It could do. I also think it actually in a way ignores or doesn’t help people who do run into problems. You know the focus used to be all on treatment and dependent people and okay there’s been a shift and that’s fine, but has the shift gone too far and when people do get into trouble…
A: There’s no…
BT: Well there’s all the services which are aimed at the early intervention and so on, but how good are the services for those who are not responding well to that.
A: You raised that in your contribution to the Witness Seminar on the Medical Council on Alcohol.
BT: Oh yes that’s right. I’d forgotten. I can’t answer the question, there might be lots of wonderful things going on and I just don’t know, but you don’t hear about them if there are.
A: No. And what about research in general?
BT: I don’t see that going back to anything and it shouldn’t necessarily, but I’d like to see the current interest in the sort of RCTs and all that sort of stuff accompanied by solid, good, long term and well –funded qualitative work. So that you don’t get one minus the other.
BT: We won’t get it.
A: No. So a pessimistic view in some ways?
BT: I’m afraid so and of course with the EU funding going, because we’ve been doing qualitative work with EU funding and then that’s going to be another loss.
A: So given your particular career or experience what other question shall we ask you?
BT: Well I did put down rather a dodgy one which I’m not sure I should have put down! There’s a big issue of the industry isn’t there, in the alcohol field and tobacco, not on drugs yet. Although I believe cannabis was raised at the Kettil Bruun meeting.
BT: I don’t know but I was told that it was raised about researchers collaborating with any industries in that way and there was a big debate about it. But anyway, personally if somebody tells me not to do something, I’m going to do it. So I was infuriated by the little wave of editorials and so on that came out in Addiction, but there were some elsewhere as well and for a while a whole sort of feeling that any researcher who collaborated, that is probably too strong a word, I can’t remember what word was used, with the industry, or worked with or whatever, it wasn’t just take research, but worked with the industry, would damage their career. That their honesty would be questioned, their work would be questioned and they would have difficulty getting published, all that sort of stuff. I think that was unfair and I think it amounts to what I consider to be professional bullying. It’s fine for researchers in my view to take an advocacy approach if they want to and if they do it upfront and say this is what I believe in and I’m coming from this point of view. But they shouldn’t have to, they should be free to talk to, work with, discuss things with anybody they like, even if that group or person are not flavour of the month and their work should be judged on its merits and not on who they’ve spoken to or who they’ve given advice to. If something is funded by the industry or by anybody else you have to declare it, but then I declare funds from the EU or from AERC or from the Government and I wouldn’t claim that that was all agenda free. So I don’t like the tension and division that’s been growing in that way, driven by public health advocates.
A: So that’s part of your criticism of the public health approach.
BT: Yes it is, or some public health, you can’t say the whole lot, but you know there is that sort of feeling. And now no one will ever fund me again to do anything in alcohol.
A: I don’t think that’s likely Betsy, you’ve been very successful.
BT: But you never know do you, once it gets out there – she talks to the industry! [Laughs.]
A: Well on that point, is there anything else you wanted to say?
BT: No I could go on forever about various people if you want.
A: Thanks very much indeed. I’ll press the stop button.
Betsy Thom was in conversation with Virginia Berridge.
The interviewee has provided an annotated bibliography of her work, available here
The full, unedited transcript of their conversation can be found here.
The opinions expressed in this commentary reflect the views of the author(s) and do not necessarily represent the opinions or official positions of the Society for the Study of Addiction.