Addiction stigma: the deep irony

October 16, 2020
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Stigma is commanded by a deep irony: where peer pressure is what likely keeps us quiet, peer support is what enables us to speak up.

Paul E Terry

One of the ways to counter stigma is for people with lived experience of addiction and recovery to share their stories. Indeed, Pat Corrigan, a respected stigma researcher, says that of the three approaches to tackling stigma – protest, education and contact – it is contact between members of stigmatised groups and ‘normal’ people that can increase understanding and dispel myths.  

Mutual aid groups offer forums where this can happen. Sadly, there is also evidence of prejudice towards such groups. In Jonathan Avery’s book, The Stigma of Addiction: An Essential Guide, which has plenty to recommend it, there is, ironically, one toe-curling section about mutual aid groups where it seems myths are not dispelled but reinforced.

Avery argues that 12-step mutual aid groups ‘perpetuate the stigma associated with’ addiction. He argues that they do this by having features which ‘run counter to a science-based understanding of the disease of addiction’. These features are:

  1. Peer-based care 
  2. Complete abstinence
  3. A paramount goal of anonymity.

He argues against these features saying:

  1. Best practice for addiction care calls for treatment to be delivered by a qualified health care professional 
  2. 12-step groups generally frown on medication; they hold abstinence up ‘as a primary goal of treatment’ 
  3. And he says that anonymity gives the impression that being in a mutual support programme is embarrassing or shameful.

Where to begin?

It’s a challenge to know where to begin with this. Ignoring the fact that, according to Kurtz, AA members had a large role in spreading and popularising the disease concept of addiction, it’s an almost laughable irony that mutual aid groups get stigmatised in a book tackling stigma in addictions. Addiction stigma is bad enough, but recovery stigma? So, what’s the deal?

Firstly, mutual aid is not treatment, nor does it set treatment goals. The clue is in the title, it’s peer to peer aid or support. It is however true that 12-step facilitation (TSF) is a structured intervention used in treatment settings that is designed to encourage uptake of community-based mutual aid groups.

As it happens and while we’re on the theme of irony, getting people to engage with AA via an intervention like 12-step facilitation has been found to be as effective, if not more effective than accepted treatment interventions like motivational enhancement therapy and cognitive behavioural therapy. So, the idea that helping people into recovery should sit entirely in the domain of the expert is not only anachronistic, paternalistic and condescending; it’s wrong. Members of mutual aid groups may not be experts on addiction treatment per se, but they are experts in community recovery.

On medication

Secondly, AA’s stance (on which they sought advice from doctors) on medication is clear – it’s wrong to deprive anyone of medication that can help, although AA rightly highlights risks of cross addiction with some medications. It’s fair to say that, as in any diverse group, individual members will have their own opinions which could differ from AA’s and be harmful, but the organisation does not condone this. 

For NA, I think it’s a bit more complex. I see it as an organisation for those seeking abstinent recovery – who don’t want to be dependent on either illicit or prescribed drugs, and there is a legitimate debate to be had about the role of MAT, but nevertheless, NA literature states: “the choice to take prescribed medication is a personal decision between a member, his or her sponsor, physician, and a higher power. It is a decision many members struggle through. It is not an issue for groups to enforce.” Hardly frowning on medication. 

On anonymity

Thirdly, while the 12-step emphasis on anonymity grew in part out of the shame and social stigmatisation associated with alcohol dependence at the time AA was set up, this was only part of the story. It was felt that people would not be likely to attend meetings where there was not the safety of remaining anonymous. That was a pragmatic approach back in the middle of the last century and it many will feel its validity stands today.

It’s not only about this though. We expect our doctors to keep our anonymity and confidentiality secure, not because we are ashamed of our health issues, but because it is an important principle that it should be up to us what we say about our medical history. 

According to AA literature, the organisation had another reason to promote anonymity. They wanted to keep all members on the same level – they aimed to maintain anonymity in the media, to avoid a cult of personality and have a goal of maintaining a degree of personal humility. 

Deep irony

However, this approach does not mean members cannot share about their recovery. As AnneMarie Ward, CEO of FAVOR UK says: “I’m an advocate because I know anonymity doesn’t mean invisibility’. Indeed, many people who do go public are members of mutual aid groups. Around the world, recovery communities are actively tackling stigma by being visible and sharing their stories.

Mutual aid groups and their members are not perfect and there are legitimate debates to be had around legitimate criticisms, but the weight of evidence for good vastly outweighs the sort of accusations Avery levels against them, even if these assertions were robust. However, the accusations are not robust, they reinforce myths about mutual aid groups and risk stigmatising them.

Now to find this in a book about addiction stigma – that’s what I call a deep irony…

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