Polarisation, tension and hostility: just another day in the field of addictions.

May 13, 2022
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Someone relatively new to the substance use disorder area asked me recently why I thought there was so much division and hostility in the addiction and recovery field, compared to other parts of health and social care. Do we really have more conflict than in some other healthcare areas? There are strongly held positions which seem impossible to reconcile in all areas of life. Is addiction policy, advocacy, treatment, support and recovery any different? 

After nearly 20 years of working exclusively in this field, my conclusion is that it probably is different. This is certainly something to be curious about. At the outset I want to be clear: I also believe that there is plenty of harmony too – much that binds us together and some great examples of collaboration in the interests of the people and families we are trying to help.

Some of the division is between harm reduction and recovery or, more precisely, around harm reduction, medication assisted treatment, and abstinent recovery. A great number of people have called this out as a false division, urging us toward a broad range of responses centred on people’s needs in the here and now and guided both by evidence and individuals’ rights to choose the recovery path that is right for them. Sometimes those voices are drowned out by polarising dissent.

Every week I hear strongly held perspectives on one side or the other of these fissures. Sometimes the antagonism to a particular approach is more subtle and we see exclusion and attitudinal barriers rather than overt criticism. At times we can tell more about an organisation’s or individual’s approach by what they don’t say. 

For instance, in some circles the words ‘recovery’ and ‘abstinence’ are rarely seen or mentioned despite being important to some people trying to resolve their substance use problems. Similarly, other people consider opioid substitution therapy to be simply replacing one addiction with another, despite compelling evidence of reduction of harms. Pressure can be put on people to detox without adequate preparation, supervision or supports in place creating avoidable risks.

The question about the vigorous level of debate and fiercely held opinion we experience in the domains of addiction, treatment and recovery is a good one without a simple answer. I’ve been thinking about this since and here is my tuppence worth.

We are passionate 

Many of us who work in addiction treatment are impassioned about substance use disorders and the responses we have to them. This passion is driven by personal and professional experience, by hope and as a response to the grim drug and alcohol deaths we see. Such passion drives beliefs and actions and can lead to progress and improvement in the lives of individuals. However, sometimes passion can be enacted as anger or arrogance. It can spill over into wrath or rage. On occasion, it can disguise fear. 

These experiences which drive passion can be self-defeating or limiting. If you have made an abstinent recovery aided by 12-step fellowships, you may come to believe that this is the only way to recover – though, to be fair, many people in mutual aid groups will readily acknowledge that there are multiple pathways to recovery. Similarly, if you are not seeing evidence of people moving on to abstinent recovery and of them leaving treatment settings, you may believe that people do not recover or that it is much too dangerous to support such a path. 

Then there is the danger of zealotry, driven by passion or fear – a blinkered approach which will not, or cannot see that we need a broad and welcoming church – a place that celebrates diverse approaches and pathways. When contempt for others creeps in, often unbidden, we diminish our effectiveness and authenticity.

This week in a newspaper I read an article where one treatment service explicitly undermined others, using misleading words. The effect was to distance the reader from some of the other good points made. The unintended consequence was disconnection, further division and a lack of positive impact. While we don’t need uniformity and we need to have the capacity to call out wrongs, we also need mutual respect. It’s a good value to hold close.

You can have no influence over those for whom you have underlying contempt.

Martin Luther King, Jr.

My fellow blogger Bill Stauffer recently noted that social media may not help us here. We connect with others who hold the same views as us and end up with confirmation bias or we get swept up in the wave of righteous indignation and then write things that are disrespectful, rude, or even threatening. 

As a relative newcomer to Twitter, I was naïve enough to be shocked initially by some responses to my early posts and to what I saw as the reasonable perspectives of others. I follow many whose views `I do not agree with, but read what they post with interest, however I don’t tolerate abuse. We behave differently online than we do in person and indeed, social media may actually harm our emotional health. I am grateful for the mute and block buttons – wonderful inventions.

We are concerned

If we see our clients/patients dying of drug and alcohol-related causes when they do move out of treatment, we may think that it is too risky for anyone ever to move on. For those of us who work in addiction treatment and support, hearing about overdose and death is a chilling, upsetting and unwelcome part of the job. But being excessively worried and anxious about the safety of those we are trying to support can lead to unhelpful consequences.

Without adequate supervision and support we can begin to live with unrelenting and harmful levels of concern. Then we can begin to get burnt out or develop dysfunctional thinking and behaviour.

Concerns about detox and abstinent recovery need to be addressed, as do those around MAT and harm reduction. Myths need to be put to bed though. Reassuringly, there are plenty of practitioners who have reconciled those concerns in a way that allows them to work passionately across all areas, mitigating risks but not in a way that stymies the capacity of people to achieve their goals. I am in awe of some of them.

We have limited resources.

When funding is tight and demand is high or services are threatened, we can reflexively respond in defensive ways, or even attack others’ services. I’ve certainly experienced that in the past – people who are normally supportive behave in ways that are difficult to understand and everybody feels hurt and upset. 

When resources are limited, you get people fighting their corner, but this can spill over into arguments about which services should be limited, have resources removed or be shut down. Think residential rehab for instance – often cited as ‘not evidence based’ by those who put their faith wholly in medical models, they can be seen as low hanging fruit when money dries up. I’ve experienced this more than once.

We get disenfranchised.

The reason we have a surge in advocacy and support for people with alcohol and drug problems is that they have not felt represented by the services set up to help them and have not felt that those services have met their needs. They have not had a voice. Or just as bad, when that voice speaks up, it is ignored, dismissed or treated with contempt. Perhaps, worst of all, individuals can sometimes be given a tokenistic place at the table – present but powerless. While huge power disparities persist, it is always difficult for lived experience to have any impact on policy and the shape of services. 

Now when voices are beginning to be heard – and in Scotland those voices are likely to become more powerful and influential through the forthcoming National Collaborative – they can feel threatening to the establishment. Yes, we have our evidence that we base our treatment offer on, but now we have new evidence of a bit of a mismatch between what we have on offer and what individuals and their families want from treatment. We have a distance to go to achieve balance.

There are those who would shut those voices down, but the likelihood is that, in terms of visibility and volume, in the future lived and living experience is not going anywhere but up.

I will ensure that local panels of people with lived and living experience are involved in all local decision making, and that a national forum or collaborative is in place to better inform our national mission.

Angela Constance, Drugs Policy Minister

We lack the breadth of experience

Years ago, a colleague who had worked in the field for years told me he’d never met anyone in long term recovery from heroin addiction. At that point, I’d met hundreds, so we could agree that we’d had very different experiences – poles apart. If professionals don’t get to see sustained abstinent recovery, instead seeing people remaining in treatment for many years or indeed experiencing too many deaths of clients or patients then of course it’s going to feel pretty risky to support people to the goal of moving out of services all together. 

Equally, although I now work in residential rehab, working in harm reduction and medication assisted treatment settings in the community has helped me see the need for a broad spectrum of approaches to help individuals achieve their goals. Recovery is dynamic and non-linear and needs flexible and wide-ranging approaches to support it. 

We are all a little prone to suffering from the Dunning Kruger effect, a cognitive bias where we think we have more knowledge and skills than we actually do on an issue. If all practitioners got to spend some time in different settings (from injecting equipment provision and wound care through to community and residential services and get a robust introduction to community recovery and support resources) then we’d perhaps seen more harmony and mutual respect.

We don’t always know ourselves 

We go into caring roles for a variety of reasons and not all those reasons are apparent to us as individuals or to others. For some of us, growing up with addiction in our families can lead to a healthy desire to help other families. For others, unresolved wounds and conflicts from early life can hamper such efforts. We may not have tended to those early wounds or even be aware that they are still tender and are influencing our behaviour in the here and now. Other formative experiences can lead to a variety of motivations.

Some of us have a desire to rescue, we might be subject to countertransference, or we can collude. I have seen harm come to individuals on occasions, thankfully rare, where over-involved practitioners with poor boundaries conspire with their clients against the very services that are most likely to be able to help them. 

When dealing with people, remember you are not dealing with creatures of logic, but with creatures of emotion, creatures bristling with prejudice, and motivated by pride and vanity.

Dale Carnegie

Some of us feel threatened when those who have depended on us for help want to become independent and move on. We may resist routes that can lead people to ‘abandon’ us. I have heard so much resistance to mutual aid, for instance, across my entire career in addictions – way beyond what is logical or reasonable – that it makes me wonder just what it is driving it. Could the lack of tolerance and acceptance be in part the fear of being divested of our charges, the pain of potential loss?

I’ve heard it said that without self-care we are prone to absorbing some of the disordered behaviours and thinking that can impair our clients – in a sense soaking up some of the pathology of addiction. Good supervision can increase insight and help to prevent this, but where supervision is not available or not utilised, disharmony and friction can develop and spread. Organisations and individuals who have a tendency to blanket-blame and shame others (others for the most part who are genuinely doing the best they can) may be suffering from this. Difficult people and difficult cultures exist, and we need to find ways to deal with them, exhausting though that may be. 

Just because you’re dealing with difficult people, does not mean that you must become like them.

David Leddick

The work is challenging

Supporting people with substance use problems can be rewarding, but it can also be challenging. The high rates of death for those with alcohol and other drug problems are distressing. Disclosure of trauma and adverse childhood experiences can be difficult to hear and leave us lingering anxiety and disquiet. Sadness, anguish and grief can steal in and set up permanent home. 

We can continue working but begin to detach or distance to the point where we become less empathic and compassionate. When we struggle like this, we may be less tolerant or even become cynical. Our relationships with others can then suffer and we take on a negative mantle but fail to recognise what’s happening. High sickness rates and excessive turnover in teams can be a reflection of this.

The way forward

And the solution to the bellicosity? You’ll need a smarter person than me to give a definitive answer to this.Addressing similar issues, Bill Stauffer quotes something that resonates with me ‘we no longer unite on things we agree on, we come together focused on things we hate’ – while this is not my whole experience, I am afraid that there is a kernel of truth here. 

Love difficult people. You are one of them.

Bob Goff

A fundamental principle to moving forward is first taking a look at the part we play in this ourselves. What’s my thinking and behaviour like?.

We must examine our own flaws and blind spots in order to understand our common ground.

Bill Stauffer

Further, were we to focus on common ground, perhaps we could bring healing and consensus. On my best days I try to find that middle way, but as I say, I’m passionate too, my opinions are forged in a crucible of fire, I react to what I understand as others’ unreasonable positions, and I have my own blind spots. Sometimes I sit comfortably in my own echo chamber. There is a real risk that we lose sight of the people who we are trying to help as we pursue our own agendas.

The reason I’m mostly writing in first person plural (‘we’) is that I recognise many of these tendencies and vulnerabilities in myself. I get passionate, frustrated, angry and hurt, but when I take ownership of these reactions rather than blaming others, it gets easier for me to move forward. If I ever get good at this, I’ll let you know.

Show respect even to people that don’t deserve it; not as a reflection of their character, but as a reflection of yours.

Dave Willis

I have learned though that I don’t have to show up to every argument I’m invited to. More positively, I have found that when you bring people together, create connection and offer a safe space for dialogue, listening and exchange of ideas, you build bridges instead of barricades. There are values that need to underpin this approach – curiosity instead of condemnation, compassion instead of conceit, kindness, respect, willingness to learn, and a genuine desire to relate to one another. 

You have brains in your head. You have feet in your shoes. You can steer yourself, any direction you choose. 

Dr. Suess

When those new to the addiction field question how unhealthy it seems, we all ought to sit up and take notice. We are responsible for the culture we have created. If that is a culture of conflict, we need to attend to it. Leaders have a particular responsibility here – we ought to be held to a high standard of behaviour and professionalism. That need not make us impotent, but rather be mindful of the power that we hold and how we use it. Change starts with ourselves.

There’s one more thing – another value – that is missing when there is turmoil. That value is humility. It’s not reasonable to expect that we all agree on everything all the time. This would be a disaster – we need to feel discomfort, disagreement and passion; these can be potent drivers for positive change, but perhaps a little bit of ‘I could be wrong and others right’ would go a long way to pour oil on troubled waters. 

Adam Grant, the organisational psychologist, nails it when he writes: ‘At the root of our polarisation problem is a deficit of intellectual humility’. 

I’ll leave you with the same question that I’m holding on to. What can I/you do to heal division and help our field to be more effective and a healthier place to practise? How do we hold our convictions passionately, be authentic in challenging poor practice and behaviours, yet foster consensus and harmony? I’m really interested to hear your thoughts.

Continue the (respectful!) discussion on Twitter @DocDavidM

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