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

2. 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

3. 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.

4. 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: )

5. 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

6. 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)

7. 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

8. 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.

9. 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)

10. 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

11. 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]

12. 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.

13. 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

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

15. 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 )
Unwilling or unable to implement a technical solution
Still a technical problem of practice

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

17. 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

18. 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.