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A Struggle for the Soul of Addiction Treatment
Scott Kellogg
October 10, 2014
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, nonexistent 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.”
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 Health earlier 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.
Continued here http://www.substance.com/a-struggle-for-the-soul-of-addiction-treatment/13798/
Scott Kellogg
October 10, 2014
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, nonexistent 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.”
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 Health earlier 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.
Continued here http://www.substance.com/a-struggle-for-the-soul-of-addiction-treatment/13798/
