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Chapter 10
Discussion
10.0 Background to the thesis revisited
The purpose of this thesis was to examine the question of whether dependence changed, to chart and describe the course of change to the extent that it did occur and to identify the factors which influenced the nature of such change. I suggested that much of the research in this subject has focussed on the development of dependence and the measurement of the condition once developed. Little attention has been paid to the course of change and particularly the course of decline. Other researchers have argued that dependence, once established, does not decline, that even in the absence of the use of the substance it endures and immediately manifests itself in its former state once use has resumed. Alternatively, dependence has been ignored by researchers as being irrelevant and use of the substance has been the primary focus of concern.
The reason for exploring the nature of change in dependence was the view that dependence is of central importance in the development of effective treatments, the quality of treatment planning decisions, the design of outcome evaluation and the interpretation of outcome data. Use of the substance has increasingly come to occupy a central place in the determination of treatment outcome goals; politicians and commissioners like to report on how many people no longer use drugs or drink alcohol beyond safe limits. The treatment provider, while concerned with these goals because they are closely associated with physical, psychological and social harm may nonetheless be equally concerned with the question of whether outcomes of abstinence or controlled use are likely to endure in the longer term. Environmental factors are clearly important in determining the longer term future of these outcomes but it has been the view of researchers and clinicians in the field that dependence at the individual level also plays a significant role. It is at the individual level that treatment services operate.
The clinical goal of arresting further deterioration in health, psychological and social functioning means that future behaviour is constantly the focus of intervention. The relationship between use and dependence and the ability of dependence to predict future use is a question of considerable importance.
Rankin and his colleagues emphasised the importance of recognising the role of dependence 213