Using the causal story behind addiction to combat stigma and discrimination
Join Together is to be congratulated for convening a national policy panel on discrimination and addiction, and for the resulting report, which highlights important changes that should be made in policies involving those in recovery.
Since unenlightened policies on addiction are often based in stigma against those struggling with dependence, it is important, as the report notes, to communicate that addiction is a chronic illness. Ordinarily, we don’t punish people for their illnesses, and as the report rightly states, punitive policies such as lifetime bans on access to public housing or receiving other benefits can only perpetuate the conditions that create and reinforce addiction.
Unfortunately, however, the disease model of addiction isn’t sufficient to completely defuse punitive attitudes and policies. As the report notes, drug or alcohol addiction begins voluntarily, and voluntary acts, if wrong or illegal, are ordinarily thought to merit blame and punishment. The report quotes Alan Leshner, who says “The recognition that addiction is a brain disease does not mean that the addict is simply a hapless victim. Having this brain disease does not absolve the addict of responsibility for his or her behavior, but it does explain why an addict cannot simply stop using drugs by sheer force of will alone” (my emphasis). So, while the disease model helps to explain the compulsive nature of addiction, the addict remains fully responsible, and thus morally blameworthy, for having become addicted by voluntarily choosing to use drugs. The moral stigma attached to addiction, therefore, remains essentially intact on this account. Those not charitably disposed toward addicts are only too happy to pounce on this chink in the disease model defense against stigma, in which case we’re unlikely to see significant changes in punitive attitudes or policies.
What might help change attitudes, however, is the recognition, amply confirmed by accumulating evidence from the biological and behavioral sciences, that the voluntary choice to use drugs is just as caused – just as necessitated by circumstances – as the compulsive addictive behavior resulting from years of substance misuse.[1] The responsibility for having used alcohol or drugs in the first place can’t be assigned to a freely willing, uncaused agent within the addict who could have simply willed otherwise. There is no such entity. Rather, the responsibility, in terms of originating causes, lies in the many factors that shaped the choice, such as genetic predisposition to addiction, the availability of drugs and alcohol, community norms sanctioning substance use, poor role modeling by parents and peers, poor education about the risks of addiction, and lack of sufficiently attractive alternatives to substance use, to name a few.
The objection will immediately arise that this sort of “absolution” for addicts goes much too far in denying a central assumption about human nature: that we could have chosen differently even given the exact circumstances (internal and external) in which the choice arose. But it is precisely this assumption that science calls into question, and it is this same assumption that underwrites moralistic, punitive attitudes and policies towards addicts (“You could have chosen differently, but you didn’t, so you are fully to blame and deserve the consequences.”). By questioning it, we stay true to the science that is progressively unraveling the etiology of addiction, and we help combat stigma and discrimination.
What we don’t do in questioning it, as many might suppose, is let addicts entirely off the hook. Holding people accountable and responsible for their choices, even though the choices are fully determined, is part of what helps change behavior. But, crucially, seeing the causal story behind addiction will ensure that accountability stays non-punitive and compassionate, since we realize that had we been in the addict’s situation – with his biology, parents, peers, and neighborhood – we would have made exactly the same unfortunate choices. We will seek to end addiction not by counterproductive jail terms, or permanent bans on receiving public assistance, but by providing adequate treatment, training, job opportunities, and housing, all so that behavior can change. Once we see improvement, then continued assistance is made contingent on maintaining the improved behavior.[2]
This is a different slant on Leshner’s point that addicts aren’t hapless victims: depending on the conditions and contingencies we set up (including pharmacotherapy such as methadone and buprenorphine), they *can* behave differently. But in holding addicts responsible in this forward-looking fashion, we’re not supposing they could have done other than what they already did in a given situation – we’re not blaming them for not acting otherwise (they couldn’t), and we’re not interested in punishing them for punishment’s sake. They don’t deserve such punishment. Rather, we’re interested in setting up non-punitive conditions which will reduce addictive behavior and substitute new, productive, self-actualizing behavior.
The “sin” of addiction, because it’s not ultimately just the addict’s doing, but the result of a network of causes, isn’t something for which he really needs absolution. Originative, causal responsibility is distributed, in that the choice to use drugs is a function of many factors, factors that must be addressed to prevent similar choices from arising in the future. But in seeking to create better choices, the addict himself is one such factor. Therefore he isn’t excused from having to meet some reasonable expectations, since that’s the only way to achieve sobriety or more responsible substance use.
What’s fundamentally changed on this naturalistic picture is the moralistic, blaming, punitive approach to addiction, an approach based on the pre-scientific view that people have cause-defying free will to transcend their biological and environmental circumstances. The moral stigma against addicts will persist as long as people suppose they have such supernatural freedom. But once we drop this supposition, we can start to discern the actual causal story behind addiction, and in its light begin designing compassionate, non-punitive approaches to changing behavior.
TWC, April 2003
Notes
[1]. See for instance Gene M. Heyman's discussion of voluntary versus involuntary behavior in "Is Addiction a Chronic, Relapsing Disease?" in Drug Addiction and Drug Policy: The Struggle to Control Dependence, Philip B. Heymann and William N. Brownsberger, editors. pp. 101-103.
[2]. What precisely does “compassionate accountability” mean? First, we have to create beneficial conditions, for instance stable housing with access to treatment and other services, under which addictive behavior can reasonably be expected to change. Once change gets underway, compassionate accountability consists in making continued provision of such benefits contingent on a continued minimum level of improved behavior (not necessarily abstinence, since that’s often an unrealistic immediate goal). This sort of accountability doesn’t ever make an addict’s life *worse* than it was at the beginning of engagement in the recovery process, which is what current punitive policies do by making sure benefits are forever denied, or withdrawing all public assistance when drug use is first discovered, or by jailing someone for using drugs. Rather, the closest it gets to being punitive is in setting up the contingency that if someone backslides, they might temporarily lose a certain benefit or privilege they originally won on the basis of improved behavior. But clients are never seen as deserving to be permanently outcast from the continuum of treatment. The essence of compassionate accountability is to use the least punitive means to effect behavior change (which in practice means using primarily rewards, not punishments), while acknowledging that the threat of losing privileges or benefits plays a role in helping people avoid relapse to unacceptable behavior. This has much in common, of course, with the treatment technique known as contingency management, but the rewards given or withheld are more broadly conceived, not limited, for instance to vouchers or cash payments.