Part 3 Literature Review
The traditional
discourse on the subject focuses on two models: the judicial and the medical.
The first has led to the War on Drugs and conceptualises the addicted user as
a criminal who needs to be punished and removed from society. Addiction is
viewed as a moral failing, or a lack of willpower (Gray 2001). This approach
is largely recognised as having failed, but it still the dominant model for
dealing with addiction at a societal level.
The second
conceptualises the addicted user as a patient in need of medical intervention
and has led to the rise of the treatment industry. There is a growing
awareness of the limitations of current approaches to treatment (Borkman 1998; White 2007a;
Keen, Sathiparsad and Taylor 2015)
. In South Africa Jeewa and Kasiram (2008: 44) found “there is
no “best treatment option” and “there are too many variations and
complexities in reaching the goal of freedom from dependence”. He also found
that the approach to treatment was founded on a “unidimensional philosophy” and that there was a need for more
comprehensive and creative approaches.
Dos Santos found that successful treatment
programs needed to be holistic, long term and focus on all aspects of life (Dos Santos et al. 2009). At present, however, treatment usually
involves a short intervention during which the addicted user is the passive
recipient of a bio-medical or psycho-social treatment program, after which
the individual is sent on their way, with little follow up. Further the
treatment is still largely based on expensive, in-patient, rehabilitation
models, inaccessible to the majority. The “expert hierarchical model” is applied,
relying on doctors, psychiatrists, nurses and other professional who are
assumed to have expert knowledge (Borkman 1998: 41).
Newer methods of dealing with addiction are
coming to the fore. Predominant among these is the social model which places
addiction firmly in a community context and conceptualises the addict as a
vulnerable and alienated member of society in need of re-integration into
their community. The two main approaches using this model are the harm
reduction and recovery schools of thought. These approaches are often
portrayed as being in conflict, but in reality have much common ground and
can complement one another (Roberts
2009; Evans, White and Lamb 2013).
Both are geared towards the normalization of life for the addicted user. In
the harm reduction model abstention is not the necessary outcome, whereas for
the recovery model abstinence is central. Opioid-substitution treatment, one
of the key options of harm reduction approaches, is controversial within the
recovery movement. Recovery supporters are concerned about the addictive
nature of opiate substitutes and speak of “methadone madness” (Neale,
Nettleton and Pickering 2012: 33). Opiate substitution
therapy has, however, been endorsed by William White, a leading figure in the
recovery movement, among others. (White and Mojer-Torres 2010).
Both the harm reduction and recovery approaches view recovery as a long term,
active process of re-connection and learning, rather than as an event (Du Pont and Humphreys 2011).
The social model,
both in the form or harm reduction and recovery, is prevalent in Europe and the Americas,
but is practically unknown in South Africa.
A search on the Sabinet SA e publications website revealed no one
single article that used the term “social model recovery” or any combination
of these words in relation to recovery from drug addiction, as opposed to a
search of international journals which turned up over a hundred. There is
however a growing body of literature on harm reduction, with the National
Drug Master Plan making reference to it
(South Africa 2012).
Writers within
the growing social model discourse place the causes of both addiction and
recovery firmly in the community (Bamber 2010; Alexander 2012;
Evans, Lamb and White 2013).
Alexander attributes addiction to what he calls “inadequate social integration”
or “dislocation”. Those suffering from dislocation construct “substitute
lifestyles” which may focus on dangerous and excessive drug use. (Alexander 2000: 502). The famous Rat Park experiment (Alexander et al. 1980) is a powerful
demonstration of this. They conceptualizes addiction as a learning or
developmental disorder, rather than a medical condition (Di Chiara 1999; Matto 2008;
Levy 2013) and argue that it should be treated as a
community health issue, (Mudavanhu
and Schenck 2014; Jagganath 2015) rather than a criminal or medical one.
Addiction is viewed as a disorder of society rather than the individual,
rooted in the alienation and dislocation so prevalent in the modern world (Alexander 2000; Bourgois
2003; White 2007b). The solution
then to problematic drug use is re-connection.
The Betty Ford
Clinic, one of the oldest and most respected treatment centers in the USA
holds up personal health and citizenship along with sobriety (abstention) as
measures of recovery (Panel 2007: 222). Also important is the emphasis the center
places on peer based support in the recovery process. This is another element
the recovery and harm reduction movements have in common. White and Evans, among others have
emphasized the significant role that non-professional recovering addicted
users can play (White and
Evans 2014). For them, community based support is often an overlooked
resource with a massive potential for assisting in the process of
recovery. The “gatekeeper myth” keeps
us believing that professionals have a better understanding of the workings
of addiction than those who have been addicts, when in reality treatment by
professionals is no more (or less) successful than programs run by recovering
addicted users (Humphreys
2015). Many too recover without any intervention (McIntosh and McKeganey 2000).
The rationale of the social model in terms of the underlying causes of
problematic drug use (and how to deal with it) is of great relevance in the
South African context where individual and community trauma and
disconnection, both current and historical, is deeply embedded. Evans et al use the term “historical
trauma” to describe a unique form of distress brought about by sustained
assault on a community’s values, through colonisation and dispossession, which could result in
increased vulnerability to drug related problems (Evans, Lamb and White 2013).
White and Evans write that “clinical and social
interventions can be substantially enriched by drawing lessons from the lived
solutions to these
problems at personal, family, neighbourhood, and community levels.” (2014: 2). If we wish to begin to utilize this resource, the experience of addicted drug users in
various stages of recovery, through the telling of their own stories, may be
the most appropriate place to begin in making sense of best practice models
for promoting recovery and the reduction of harms that addiction creates to
individuals, their families their community and society at large.
This dissertation draws on the
recovery approach in analysing the oral histories and in engaging with
existing and future policy and treatment models.
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