The traditional
discourse on the subject of drug addiction 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 in
this model is viewed as a moral failing, or a lack of willpower (Gray 2001). Treatment is
seen as punitive, with jails or militaristic “boot camp” type institutions
being the preferred destination not only of addicted users, but of all who have
fallen foul of the drug laws. The UN Global Commission on Drug Policy, made up
of imminent persons, including former heads of state, business leaders and
renowned artists states quite plainly : “The global war on drugs has failed…
policy makers believed that harsh law enforcement action against those involved
in drug production, distribution and use
would lead to an ever-diminishing market in controlled drugs such as heroin,
cocaine and cannabis, and the eventual achievement of a “drug-free world”. In practice
the global scale of illegal drug markets- largely controlled by organized
crime- has grown dramatically over this period.” (2011:4). Rolles et al (2018:8) estimate the annual cost
of the War on Drugs exceeded 100 billion dollars, while profits from the annual
trade in illicit drugs exceeded 330 billion dollars. It is, however, still the
dominant model for dealing with addiction at a global level.
The second approach
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). I have stated some of these limitations in
section 2 (The Context), others will be explored below.
In South Africa
this has been the dominant model of treatment. Jeewa and Kasiram (2008: 44) found, that in
this country, “there is no “best treatment option” and “there are too many
variations and complexities in reaching the goal of freedom from dependence.”
They 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, a practicing psychiatrist and
head of the South African Foundation for Professional Development, 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 stay in a private institution. In South
Africa medical aids only pay for one month treatment, so this is the usual duration,
but this may be extended to three months. During this time the addicted user is
the passive recipient of a bio-medical or psychological treatment program,
after which they are sent on their way with little, if any follow up.
Further only about
16% of South Africans are on medical aid schemes (Myers 2013). The remaining
84% are dependent on public service, and for the most part can’t afford private
care, where treatment is still largely based on
expensive, in-patient, rehabilitation models . Treatment for heroin addicts in
the public sector is virtually non-existent, and while government
rehabilitation centres have opened, they offer no detoxification or
substitution treatment and have a long term waiting period to get in. In both
public and private sector, the
“expert hierarchical model” is applied, relying on doctors, psychiatrists,
nurses and other professional who are assumed to have expert knowledge of addiction. (Borkman 1998:
41). 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).
Perhaps the biggest
deficit with the medical model is that little attention is paid to social
factors which may be involved in causing addiction, and the circumstances to
which people return when they leave
in-patient based treatment centres. (Borkmann 1998: 42; Jeewa and Kasiram 2008).
These deficits are
now well documented and have given rise
to a rethinking of the treatment of drug
dependence and addiction. Since the latter half of the 20th Century 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 addicted user 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. The harm reduction model looks to reducing the harms done by
drugs, both to society and the individual using pragmatic, non-judgmental
interventions. (Public Awareness Task Group 2007: 4) Among these are needle exchange programs,
controlled drug using spaces, and Opioid Substitution Therapy. Abstention is
not the necessary outcome. While in the recovery model, abstention is seen as
the ultimate goal, other measures of success are seen as equally important. The
Betty Ford Clinic, one of the oldest and most respected recovery based centres
in the USA, holds up personal health, citizenship and social integration along
with sobriety (abstention) as measures of recovery (Panel 2007: 222).
Writers within the
growing social model discourse encompassing both harm reduction and recovery,
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
al1980) is a powerful demonstration of this effect. 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.
In his more recent work, Alexander (2012),
goes further than this. Elaborating on his Rat Park experiment, he sees drug
addiction as the manifestation of a greater problem in our society. The problem
he sees is that addiction, in all its forms, not just drug addiction, is a way
of adapting to the sustained dislocation of globalisation. The only way we can
tackle this problem in the long run, he believes, is through large scale social
and political changes. This is not in contrast to the social model, but rather
can be seen as the extreme, but logical outcome of its premises.
Treatment, in the social model
requires long-term intervention of re-integration back into society. Both
social model schools view recovery as a long term, active process of
re-connection and learning, rather than as an event (Du Pont and Humphreys
2011).
The harm reductionists believe this
can be achieved by ensuring that addicted users who opt to stop using illicit
drugs have access to Opioid Substitution Therapy. OST is viewed as a platform
for re-integration and normalisation and provides the user with a degree of
stability in their lives, unattainable while using heroin. OST 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).
Recovery proponents
believe that an addictive lifestyle exacerbates the initial disconnection that
causes it. Thus long- term process of re-connection, and learning to live a
drug free lifestyle is necessary to address all the issues involved which initially
led the individual, and may lead them
back, to using drugs (White 2007: 231). The previously addicted user is
encouraged to participate in a program which may include personal or family
counselling, attending support groups, vocational and life skills training
workshops, participating in community service, access to resources
(transportation, housing, employment) and clean-living social, creative and
sporting events among other activities.
In South Africa the
best known proponent of recovery ideas are the 12-step fellowships of Narcotics
and Alcoholics Anonymous. These groups can claim some success based on
international membership running into the millions. Self-conducted surveys of
these groups show that AA comprised of 120 00 weekly meetings, while NA in 2013
held over 63 000 meetings a week in 132 countries (NA 2013; AA 2014).
While these groups form an important historical role in the formation of the
recovery movement, many in the movement are critical of these organisations for
various reasons. Among these are the focus on abstinence and the insistence on
anonymity (other reasons will be explored in the study) and they are not
representative of the movement as a whole.
Another important
element the recovery and harm reduction movements have in common is the
emphasis on peer based support. White
and Evans, among others have emphasized the significant role that
non-professional recovering addicted users can play (White and Evans 2014). Contact
with recovering addicted users is important as it provides a sense of hope to
the using addict, and access to a new circle of friends. According to White and
Mojer- Torres (2010:99), one of the key indicators of long term recovery is the
extent to which the previously addicted user makes changes in their lives,
moving away from old friends, places, habits and finding healthier, drug-free alternatives.
A “culture of recovery” can be built to replace the drug filled lifestyle in
which the addicted user becomes enmeshed.
Other writers
influenced by the social model conceptualise addiction as a learning or developmental
disorder, rather than a medical condition (Di Chiarra 1999; Matto 2008; Levy 2013) and argue it should be
treated as a community health issue (Mudavahnu and Schenk 2014: Jagganath 2015)
rather than a medical or criminal one.
The social model,
both in the form of 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
single article that used the words “social model recovery” or any combination
of these words in relation to recovery from addiction, as opposed to
international sites which turned up over a hundred. There is however a small
but growing body of literature on harm reduction, with the National Drug Master
Plan making reference to it.
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 etal 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. (2013). Recovery of individuals can further be the starting point for
recovery of affected communities.
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 may be the most
appropriate place to begin. Through listening to their stories we can
begin to make sense, not only of the
reasons that people become addicted, but more importantly how and why they recover.
The insight gained from the lived experience of
people surviving addiction can
then applied to present policy and treatment models, leading to a greater understanding of the
best practices for promoting recovery and the reduction of harms that addiction
creates to individuals, their families their community and society at large.
In this proposal I
have addressed only some of the issues involved in the debate around treatment
and recovery, drawing on those which are prevalent in the literature, and my
own experience as a recovering addicted user. Through the oral histories of
recovering addicted users others issues are expected to emerge, revealing
further the strengths and weaknesses of present policy and treatment models,
and will be explored.
In terms of a theoretical approach, this study draws on the social model,
and more particularly the recovery paradigm in its understanding both of
addiction and recovery. This will lay the theoretical groundwork for analysing
the oral histories and in engaging with existing and future policy and
treatment models. However, serious consideration will be given in this study to
the harm reduction approach given its centrality in the global discourse on
drug use disorders and its treatment. Differences and commonalities between the
two approaches will be explored in some detail in the literature review in the
study, and will frame the conversations that will be held with participants in
this study.
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