Anyone who believes in progressive drug policy reform and in embracing a more humanistic system of care would agree that we are living in a time when amazing things are happening. Both the Global Commission on Drug Policy and the Drug Policy Alliance, among others, have helped us realize that the War on Drugs has actually been a war on people, and that while drug use can clearly be destructive, the impact of prohibition and incarceration is frequently even worse. It is also an exciting time in the field of addiction treatment because that, too, is in the middle of a major paradigm struggle. The question at the heart of this conflict is: Are individuals who have difficulties with drugs and alcohol bad people who should be punished or sick people in need of healing?
THE MORAL/SOCIAL MODEL: THE 'BAD' TRADITION
The mainstream addiction treatment system is filled with thousands of dedicated and compassionate clinicians and other professionals. Nonetheless, the belief that people who use drugs and alcohol in problematic ways are fundamentally bad is an assumption that permeates the system. It is also at the heart of what I call the Moral/Social model of treatment.
This model is not only supported by the larger culture and the criminal justice system, but also, tragically, by the 12-step fellowship tradition and the Therapeutic Community movement. “In the AA understanding, the core of alcoholism, the deep root of alcoholic behavior, lies in character,” write Dr. William Miller and Dr. Ernest Kurtz in “Models of Alcoholism Used in Treatment.” “‘Selfishness—self-centeredness! That, we think, is the root of our troubles,’ reads a key passage of AA’s description of ‘How It Works.’”
In turn, Dr. George De Leon, a student of therapeutic communities, emphasized the importance of values and morals in the Therapeutic Community model. “Drug abuse is regarded as a disorder of the whole person.... Cognitive, behavioral, and mood disturbances appear, as do medical problems; thinking may be unrealistic or disorganized; and values are confused, non-existent, or antisocial. Frequently there are deficits in verbal, reading, writing, and marketable skills. Finally, whether couched in existential or psychological terms, moral issues are apparent,” he wrote in “The Therapeutic Community: Toward a General Model.”
The philosophy of judgment, punishment, and control is so pervasive and engrained that highly trained, well-meaning mainstream clinicians utilize it even as they set out to do something good for their patients.
To be fair, mutual aid societies are free to have any beliefs they wish, and the Therapeutic Community movement continues to evolve. Nonetheless, this underlying moral vision has, at times, served as a foundation for attitudes and actions toward addicted patients that we would deem to be unacceptable for patients with other disorders. (I call this a social model because of the overwhelming emphasis on groups as a vehicle for change. This stands in direct contrast to the general emphasis on individual therapy in the treatment of other psychiatric or mental health disorders.)
A recent example of this model’s continuing influence can be seen in a report released by the Institute for Behavior and Healthearlier this year. Entitled “The New Paradigm for Recovery,” the report was spearheaded by psychiatrist Robert DuPont, a former drug czar and director of the National Institute on Drug Abuse (NIDA). Starting in a scientific vein, the report affirms NIDA’s view that substance use disorders are now understood to be a chronic disease that involves a “hijacked” brain.
But in an unexpected shift, the authors then advocate for a public policy that promotes the stigmatization of problematic substance use: “Unhealthy patterns of drug and alcohol use warrant ‘stigma,’ to warn others to avoid such behaviors and to help persons engaged in such behaviors [to] identify the need for help.” (This recommendation is quite striking because there have been a number of efforts to reduce the stigma around addiction, including some by NIDA.) Although the IBH report clarifies that it is the behavior, not the person, that should be stigmatized, it seems to me that the damage is already done.
In terms of treatment, the patient is seen as being in need of external control because their brain has been hijacked by the addiction. The report recommends that following formal treatment, the individual should become involved in an accountable system of care management that includes (1) signing an abstinence contract and (2) agreeing to be under a supervisory or monitoring authority (family, employer, legal entity) that (3) subjects them to frequent random drug testing and (4) provides negative sanctions for any lapses, relapses, or missed drug testing, while (5) encouraging or mandating attendance at mutual aid groups. Despite the use of “disease” language, the report promotes a moral/social model.
It is too early to determine whether this report will have any long-term influence. But it is notable that the working group that produced the report included, in addition to DuPont, such major figures in the field of addiction as Dr. Stuart Gitlow, the president of the American Society of Addiction Medicine; Dr. John Kelly, a major researcher on recovery at Harvard University; Dr. Marvin Seppala, chief medical officer at the Hazelden Foundation; Dr. Gregory Skipper, director of Professional Health Services at Promises Treatment Center; and William White, one of the leading proponents of Recovery Management and a major addiction treatment historian. What this demonstrates is that the philosophy of judgment, punishment, and control is so pervasive and engrained that highly trained, well-meaning mainstream clinicians utilize it even as they set out to do something good for their patients.
On a global scale, the policy of stigmatizing and punishing drug users has had many horrendous consequences, as was affirmed in the 2006 Vancouver Declaration, a manifesto by former and active drug users: “We are people who have been marginalized and discriminated against; we have been killed, harmed unnecessarily, put in jail, depicted as evil and stereotyped as dangerous and disposable.”
THE SCIENTIFIC/HUMANIST MODEL: THE 'SICK' ALTERNATIVE
This model is built on the belief that individuals with serious drug or alcohol problems are sick or in pain and therefore in need of treatment and healing. This model has emerged over the past 45 years out of the confluence of five major therapeutic streams:
1. Neuroscience,addiction medications and the burgeoning efforts to re-balance the limbic system and the pre-frontal cortex.
2. Evidence-basedpsychological and behavioral interventions such as Dr. Alan Marlatt’s Relapse Prevention, Dr. William Miller and Dr. Stephen Rollnick’s Motivational Interviewing, and Dr. Maxine Stitzer’s Contingency Management.
3. Addiction-orienteddepth psychologies, such as Dr. Edward Khantzian’s idea that problematic substance use can be a form of self-medication and Dr. Leon Wurmser’s idea that drug use may serve as an escape from self-hatred.
4.The Harm Reduction movement, including needle exchange, safe injection sites, heroin maintenance, and naloxone.
5.Harm Reduction Psychotherapy, which is built on the philosophies and practices of these four approaches and has been pioneered by, among others, Dr. Marlatt, Edith Springer, Jeannie Little, Dr. Patt Denning, Dr. Stanton Peele, Dr. Debra Rothschild, Dr. Tom Horvath, and, most significantly, Dr. Andrew Tatarsky.
A 'MEANINGFUL' APPROACH TO DRUG USE
Central to the scientific/humanist vision is the understanding that problematic drug use is a complex and meaningful behavior: People take substances for reasons that need to be respected and sometimes addressed before they will be willing to make any significant changes. There are six main factors supporting substance use:
1. Drug use brings pleasure: Drugs and alcohol help some people access states of happiness, pleasure, and creativity that they might not otherwise attain.
2. Self-medication: People use substances to address emotional pain, trauma, and psychopathology.
3. Brain Changes: Drugs affect brain function, and the resulting structural changes and neurotransmitter imbalances can lead to cravings, urges, and withdrawal symptoms.
4. Physical Pain: Chronic pain is a major medical problem in America. As a consequence, people use substances to relieve physical suffering.
5. Social Identity: People may drink both to be a member of a group and as a reflection of a socially based identity. When deciding to stop or change, many will also have to face the challenge of giving up a world of friendships and connections.
6. Social Oppression: Social degradation, violence, poverty, homophobia, and homelessness can all contribute to the use of substances for coping—for example, by helping create a wall of psychic protection against the painful impingements of society.
While there are factors that drive problematic use, there are also forces at work within the individual that can motivate change. These include concerns about: family and important relationships; job and prestige loss; legal issues and incarceration; health problems; existential and spiritual issues; and the exhaustion and “burnout” that come from trying to maintain an addiction.
TREATMENT: MOTIVATION AND MEDICINE
An essential part of treatment involves engaging with these motivational forces. On the one side, there are the parts of the person that are concerned with managing and reducing their pain and suffering while also trying to bring some pleasure into their life; on the other, there are the parts that are frightened about the how the drug use is impacting them as well as those that are hoping for a better future.
When traditionalists use the term "disease," they are speaking metaphorically. It is a way of understanding the experiences of loss of control and relapse and helping people stay vigilant.
Treatment anchored in this paradigm includes components such as privileging individual psychotherapy over the use of groups and mutual aid organizations, emphasizing the central importance of the therapeutic relationship, working with both the motivations to use and those to change, being willing to start treatment with goals other than abstinence, using evidence-based practices, integrating harm reduction and moderation techniques in the work, focusing on patient empowerment, and utilizing addiction-focused and psychiatric medications in a judicious manner.
Proponents of the traditional addiction treatment system argue that it is scientific because it is working with a “disease model”; this, however, is not accurate. When traditionalists use the term “disease,” they are usually speaking metaphorically. It is a way of understanding and explaining the experiences of loss of control and relapse; it is also a way to help people stay vigilant and to be cognizant of their vulnerabilities. The fact that they do not really believe it is a “disease” can be seen in the ongoing opposition to methadone, buprenorphine, and, to a lesser extent, psychiatric medications. In the Western world, we treat diseases with medicines. If you do not allow for the use of medicines in the treatment of addiction, then you fundamentally do not believe that it is a disease.
CAN PROGRESSIVES MAKE PROGRESS?
How can drug policy progressives and scientific/humanist treatment professionals work together? I can think of two important ways.
1. People use many paths to overcome their addictions, but there is one commonality: Whether they find freedom on their own or by attending a mutual aid society, becoming active in a needle exchange, following a religious or spiritual path, becoming a member of a drug users organization, or working on their lives in psychotherapy, all will successfully fight for and maintain a meaningful and rewarding identity that supplants their previous one based on problematic substance use. This is a core component of all successful long-term change—whether it is centered on moderation or abstinence.
The war on drugs, however, traps people in their addictions. By blocking access to money for education and dramatically harming an individual’s ability to find employment after prison, people who are wrestling with substance use problems are deprived on the major vehicles for identity creation. Ending the War on Drugs and developing effective educational and vocational programs can support the development of personal complexity and healing.
2. Progressive forces could more consciously and purposefully endorse the scientific/humanist model. To date, these groups have supported harm reduction and evidence-based practices, but they have yet to embrace the idea that addiction is a mental health disorder that is frequently rooted in trauma and self-hatred.
It would be useful to promote an ongoing discussion about this idea, and a good place to start is with the Adverse Childhood Experiences Study, which was jointly developed by the Centers for Disease Control and Kaiser Permanente. This large-scale study found compelling connections between, on the one hand, childhood abuse and neglect, and, on the other, problems with drugs and alcohol, obesity, depression, high-risk sexual behavior, suicide, and a range of other medical and behavioral issues. As the authors show, what were previously thought of as public health issues have turned out to be ways of coping with adversity.