Defining addiction and problem ownership
Yesterday’s post and the discussion around it brought up a lot of good questions. Among them was the question, does it really matter whether we call it a disease?
It prompted me to look at some old posts. I’ll share versions of a few of them in the coming days.
A few variations of this have been posted over the years.
How we define addiction determines which helpers and which systems own the problem. The opioid crisis has been moving into medicine (both addiction specific and general medicine), but also into public health, mental health, criminal justice, etc.
Of course, the categorically segregated addiction treatment system has had serious problems with ethics, stewardship, and quality. There’s also no doubt that these debates can turn into turf issues. However, it’s worth considering how a categorically segregated system emerged to determine what should be protected and what can be modified or discarded. How problem definition fits into that history is an important element.
On problem ownership:
Whether we define alcoholism as a sin, a crime, a disease, a social problem, or a product of economic deprivation determines whether this society assigns that problem to the care of the priest, police officer, doctor, addiction counselor, social worker, urban planner, or community activist. The model chosen will determine the fate of untold numbers of alcoholics and addicts and untold numbers of social institutions and professional careers.
The existence of a “treatment industry” and its “ownership” of the problem of addiction should not be taken for granted. Sweeping shifts in values and changes in the alignment of major social institutions might pass ownership of this problem to another group.
On the segregation-integration pendulum:
American history is replete with failed efforts to integrate the care of alcoholics and addicts into other helping systems. These failed experiments are followed by efforts to move such care into a categorically segregated system that, once achieved, is followed with renewed proposals for service integration. After fighting 40 years to be born as an autonomous field of service, addiction treatment is once again in the throes of service-integration mania. This cynical evolution in the organization of addiction treatment services seems to be part of two broader pendulum swings in the broader culture, between specialization and generalization and between centralization and decentralization. Once we have destroyed most of the categorically segregated addiction treatment institutions in America, a grassroots movement will likely arise again to recreate them.
If AOD problems could be solved by physically unraveling the person-drug relationship, only physicians and nurses trained in the mechanics of detoxification would be needed to address these problems. If AOD problems were simply a symptom of untreated psychiatric illness, more psychiatrists, not addiction counselors would be needed. If these problems were only a reflection of grief, trauma, family disturbance, economic distress, or cultural oppression, we would need psychologists, social workers, vocational counselors, and social activists rather than addiction counselors. Historically, other professions conveyed to the addict that other problems were the source of addiction and their resolution was the pathway to recovery. Addiction counseling was built on the failure of this premise. The addiction counselor offered a distinctly different view: “All that you have been and will be flows from the problem of addiction and how you respond or fail to respond to it.”
Addiction counseling as a profession rests on the proposition that AOD problems reach a point of self-contained independence from their initiating roots and that direct knowledge of addiction, its specialized treatment, and the processes of long-term recovery provide the most viable instrument for healing and wholeness. If these core understandings are ever lost, the essence of addiction counseling will have died even if the title and its institutional trappings survive. We must be cautious in our emulation of other helping professions. We must not forget that the failure of these professions to adequately understand and treat addiction constituted the germinating soil of addiction counseling as a specialized profession.
On the risks of diffusion and diversion:
Diffusion and diversion constitute two of the most pervasive threats in the history of addiction treatment institutions and mutual-aid societies. Diffusion is the dissipation of an organization’s core values and identity, most often as a result of rapid expansion and diversification. Diffusion creates a porous organization (or field) that is vulnerable to corruption and consumption by people and institutions in its operating environment. Diversion occurs when an organization follows what appears to be an opportunity, only to discover in retrospect that this venture propelled the organization away from its primary mission.
The current absorption of addiction treatment into the broader identity of behavioral health is an example of a diffusion process that might replicate two earlier periods – the absorption of inebriate asylums into insane asylums and the integration of alcoholism and drug-abuse counseling into community mental health centers in the 1960s. This diffusion-by-integration has generally led to two undesirable consequences: 1) the erosion of core addiction treatment technologies; and 2) the diversion of financial and human resources earmarked to support addiction treatment into other problem arenas.