Post by Admin on Nov 27, 2020 18:47:06 GMT
In Neuroethics, philosopher Hanna Pickard offers a new framework for thinking about addiction that neither disempowers the individual (as the disease model does) nor stigmatizes them (as the choice model can). She calls it a Responsibility without Blame framework, and it draws on her work as a clinician.
According to Pickard, this framework can help us “acknowledge the truth about choice and agency in addiction, while avoiding stigma and blame, and maintaining care and compassion…”
New Addiction Framework to Empower Patients and Reduce Stigma
Philosopher Hanna Pickard's "Responsibility without Blame" model interrogates common assumptions about addiction and offers a new way forward.
www.madinamerica.com/2020/11/new-addiction-framework-empowers-patients-reduce-stigma/
Responsibility without Blame for Addiction
Hanna Pickard
Neuroethics volume 10, pages169–180(2017)
link.springer.com/article/10.1007/s12152-016-9295-2
Abstract
Drug use and drug addiction are severely stigmatised around the world. Marc Lewis does not frame his learning model of addiction as a choice model out of concern that to do so further encourages stigma and blame. Yet the evidence in support of a choice model is increasingly strong as well as consonant with core elements of his learning model. I offer a responsibility without blame framework that derives from reflection on forms of clinical practice that support change and recovery in patients who cause harm to themselves and others. This framework can be used to interrogate our own attitudes and responses, so that we can better see how to acknowledge the truth about choice and agency in addiction, while avoiding stigma and blame, and instead maintaining care and compassion alongside a commitment to working for social justice and good.
Drug use and drug addiction are severely stigmatised around the world.Footnote1 Cross-cultural studies suggest that social disapproval of addiction is greater than social disapproval of a range of highly stigmatised conditions, including leprosy, HIV positive status, homelessness, dirtiness, neglect of children, and a criminal record for burglary [1]. The 1961 UN Single Convention on Narcotic Drugs refers to drug addiction as “a serious evil for the individual” and “a social and economic danger to [hu]mankind” [2]. Our common language also expresses stigma: people who use drugs are “junkies”, mothers who use drugs are “crack moms”, and abstinence is called “getting clean” – implying, of course, that when people use drugs they are dirty. Lurid, dark images of drug use and addiction abound in the media [3].Footnote2 Moreover, given that possession and trafficking of many kinds of psychoactive substances are almost universally criminalised, the stigma associated with criminal offending also contributes to the stigma surrounding drug use and addiction.Footnote3
Stigma is a mark of social disgrace. It carries condemnation and ostracization by society and, typically, creates corresponding shame and isolation on the part of the stigmatized person.Footnote4 Stigma commonly impacts on the self-identity and self-esteem of drug users and addicts themselves [8] as well as presenting a psychological obstacle to seeking treatment [9]. It also has concrete practical consequences. In many parts of the world, drug addiction and drug convictions are formal barriers to healthcare, housing, benefits, employment, financial loans, and the right to vote; they may also result in long-term surveillance, forced labour, and torture and abuse during detention [10].Footnote5 Finally, although levels of drug use are relatively stable across different sectors of society, drug addiction and conviction rates are not equally distributed, but fall disproportionately on individuals who are otherwise vulnerable and disadvantaged, such as people who come from underprivileged socioeconomic backgrounds, have suffered from childhood abuse and adversity, struggle with mental health problems, or are members of minority ethnic groups or other groups subjected to prejudice and discrimination [10–16]. As a result, they bear a disproportionate share of the burden of the stigma and associated consequences surrounding drug use.
Why are drug users and addicts subjected to stigma and harsh treatment? No doubt a full explanation depends on a variety of complicated historical, socio-political and economic forces. But from an ideological perspective, we must also recognise how much these attitudes and policies resonate with the moral model of addiction which was dominant in the first half of the twentieth Century.
The moral model of addiction has two distinctive features. First, it views drug use as a choice, even for addicts. Second, it adopts a critical moral stance against this choice. Addicts are considered people of bad character with antisocial values: selfish and lazy, they supposedly value pleasure, idleness and escape above all else, and are willing to pursue these at any cost to themselves or others. In contemporary Western culture, we typically hold people responsible for actions if they have a choice and so could do otherwise, and we excuse people from responsibility if they don’t. Because the moral model of addiction sees drug use as a choice, it views addicts as responsible; because it condemns this choice, it views them as to blame – potentially deserving of the stigma and harsh treatment they in fact receive. For this reason, in so far as the moral model continues to influence – whether implicitly or explicitly – conceptions of drug use and drug addiction, the prejudice and injustices to which drug users and addicts are subjected around the world may appear justifiable.
For those who recoil from the attitudes embodied in the moral model, the disease model of addiction can appear by contrast to offer a desperately needed ideological corrective. Our concept of disease is not precise, and may well have different meanings and implications in different contexts of use [17]. However, with respect to models of addiction, the meaning and implication is relatively clear: “When addiction specialists say that addiction is a disease, they mean that drug use has become involuntary” [18]. According to the disease model, addiction is a chronic, relapsing neurobiological disease characterised by compulsive use despite negative consequences. Repeated drug use is supposed to change the brain so as to render the desire for drugs irresistible: the disease model maintains that addicts literally cannot help using drugs and have no choice over consumption. Compulsion can serve to explain why addicts persist in using despite the harm their use causes: if they could stop using, they would – but they can’t, so they don’t [19, 20]. But, as a result, it also removes responsibility and with it the potential for blame. The disease model of addiction can therefore serve to combat any apparent legitimacy that the stigma and harsh treatment of drug addicts might otherwise be perceived to have.Footnote6 With the pernicious influence of the moral model of addiction in the background, the disease model emerges as a call for compassion and a force for social justice and good.Footnote7
Strikingly, Marc Lewis rejects both a choice model and a disease model, offering instead what he calls a learning model of addiction. In his view, a choice model invites and offers to legitimate a critical moral stance: “Unfortunately, the choice model provides a convenient platform for those who consider addicts indulgent and selfish. If addiction is a choice, they reason, then addicts are deliberately inflicting harm on themselves and, more seriously, on others” [21]. But a disease model fares no better according to Lewis, for it wrongly pathologizes both the brain and the person. It wrongly pathologizes the brain because, in his view, the brain changes caused by repeated drug use are not evidence of pathology but of neuroplasticity: a part of the ordinary process of learning and habit formation that occurs when the brain is exposed to reward. It wrongly pathologizes the person because most addicts do not think of themselves as having a disease. Nor would it be good for them were they to do so: self-conceiving as a helpless victim of a disease and adopting the “sick role” [22] risks placing addicts in a position whereby they view themselves as dependent on medical and associated professionals for a “cure”.Footnote8 Yet, as Lewis emphasises, the personal experience and stories of the majority of people who have overcome their addiction to whatever degree typically involve a sense of agency and empowerment, alongside the fashioning and enacting of a life narrative that makes sense of the past while telling the story of a different future [21, 24, 25]. Crudely, addicts must come to want different things and to make different choices to overcome their addiction. Anything that helps with this task – pharmacological interventions that reduce cravings or stabilise patterns of consumption enabling gradual, monitored reduction; peer support and a sense of belonging; education and employment opportunities; the support of friends and family; books, hobbies, new pleasures; cognitive and psychological therapy; contingency management treatment; narrative self-understanding – should be used. But, to borrow a phrase from Lewis, addiction is “uncannily normal” through and through [21] – not a disease requiring specialised medical treatment, but a product of ordinary learning and development which can be overcome through further learning and development, in the form of personal growth and self-understanding.
I agree with Lewis that addiction is not a disease – at least given the typical meaning and implications of that concept. I am also sceptical that, given the state of our current understanding and evidence, we are justified in maintaining that the brain changes caused by repeated drug use are correctly classified as pathological. And I believe Lewis is correct to emphasise the central importance of a sense of agency, empowerment, and personal growth and self-understanding, in overcoming addiction. But I do not agree that we must reject a choice model of addiction.
There are two straightforward reasons why. The first is that the evidence is ever-increasing that, however hard it is for addicts to control their use, and however important it is for others to recognize and respect this struggle, addicts are not in fact compelled to use but have choice over their consumption in many circumstances. To briefly review some of this evidence: Anecdotal and first-person reports abound of addicts (including those with a DSM-based diagnosis of dependence) going “cold turkey” [13, 18]. Large-scale epidemiological studies demonstrate that the majority of addicts “mature out” without clinical intervention in their late twenties and early thirties, as the responsibilities and opportunities of adulthood, such as parenthood and employment, increase [13, 16, 26, 27]. Rates of use are cost-sensitive: indeed, some addicts choose to undergo withdrawal in order to decrease tolerance, thereby reducing the cost of future use [28]. There is increasing evidence that Contingency Management treatment improves abstinence and treatment-compliance, compared to standard forms of treatment such as counselling and cognitive-behavioural therapy, by offering a reward structure of alternative goods, such as modest monetary incentives and small prizes, on condition that addicts produce clean urine samples [29]. Experimental studies show that, when offered a choice between taking drugs or receiving money then and there in the laboratory setting, addicts will frequently choose money over drugs [30, 31]. Finally, since Bruce Alexander’s seminal experiment “Rat Park” first intimated that something similar might be true of rats [32, 33], animal research on addiction has convincingly demonstrated that, although the majority of cocaine-addicted rats will escalate self-administration, sometimes to the point of death, if no alternative goods are available, they will by contrast forego cocaine and choose alternative goods, such as saccharin or same-sex snuggling, if available [34, 35].Footnote9 In short, the evidence is strong that drug use in addiction is not involuntary: addicts are responsive to incentives and so have choice and a degree of control over their consumption in a great many circumstances.Footnote10
The second reason to maintain a choice model of addiction is that the process of overcoming addiction through a sense of agency, empowerment, and personal growth and self-understanding – a process that Lewis describes in The Biology of Desire [21] with great care and acuity – itself presupposes that addicts have choice and a degree of control. Agency needs to exist to be mobilized: you can only decide to quit and do what it takes to stop using and change how you live and the kind of person you are if you have some choice and control over your use and your identity. The “uncannily normal” road away from addiction is paved by ordinary moments in life where choices are made, resolve is hardened, and reflection and narrative is used to understand and buttress them. Of course, not all interventions that help addicts make changes involve choice – many things will always lie outside of our control – but choice and cognate psychological processes are nonetheless crucial elements in most if not all accounts of life changes that flow from personal growth and self-understanding, and it can be important and indeed empowering for this to be recognized and acknowledged [21, 37–39].Footnote11
Recall that the moral model of addiction has two features. It views drug use as a choice. And it adopts a critical moral stance against this choice. Because of the evidence that addicts respond to incentives and the role of choice and cognate psychological processes that involve agency in overcoming addiction, I believe we must accept the first feature. But that does not mean we must also accept the second. Just as addicts have choices with respect to drug use, we have choices with respect to how we respond to people who use drugs. In what follows, I offer a framework that can help us interrogate our own attitudes and responses, so that we can better see how to acknowledge the truth about choice in addiction, while maintaining care, compassion and a commitment to social justice and good. The framework derives from philosophical reflection on my personal experience working with patients whose behaviour causes them and others harm. The key is to better distinguish our concept of responsibility from our concept of blame, so that we can acknowledge agency and with it responsibility, without thereby immediately inviting let alone legitimating stigma and blame.
According to Pickard, this framework can help us “acknowledge the truth about choice and agency in addiction, while avoiding stigma and blame, and maintaining care and compassion…”
New Addiction Framework to Empower Patients and Reduce Stigma
Philosopher Hanna Pickard's "Responsibility without Blame" model interrogates common assumptions about addiction and offers a new way forward.
www.madinamerica.com/2020/11/new-addiction-framework-empowers-patients-reduce-stigma/
Responsibility without Blame for Addiction
Hanna Pickard
Neuroethics volume 10, pages169–180(2017)
link.springer.com/article/10.1007/s12152-016-9295-2
Abstract
Drug use and drug addiction are severely stigmatised around the world. Marc Lewis does not frame his learning model of addiction as a choice model out of concern that to do so further encourages stigma and blame. Yet the evidence in support of a choice model is increasingly strong as well as consonant with core elements of his learning model. I offer a responsibility without blame framework that derives from reflection on forms of clinical practice that support change and recovery in patients who cause harm to themselves and others. This framework can be used to interrogate our own attitudes and responses, so that we can better see how to acknowledge the truth about choice and agency in addiction, while avoiding stigma and blame, and instead maintaining care and compassion alongside a commitment to working for social justice and good.
Drug use and drug addiction are severely stigmatised around the world.Footnote1 Cross-cultural studies suggest that social disapproval of addiction is greater than social disapproval of a range of highly stigmatised conditions, including leprosy, HIV positive status, homelessness, dirtiness, neglect of children, and a criminal record for burglary [1]. The 1961 UN Single Convention on Narcotic Drugs refers to drug addiction as “a serious evil for the individual” and “a social and economic danger to [hu]mankind” [2]. Our common language also expresses stigma: people who use drugs are “junkies”, mothers who use drugs are “crack moms”, and abstinence is called “getting clean” – implying, of course, that when people use drugs they are dirty. Lurid, dark images of drug use and addiction abound in the media [3].Footnote2 Moreover, given that possession and trafficking of many kinds of psychoactive substances are almost universally criminalised, the stigma associated with criminal offending also contributes to the stigma surrounding drug use and addiction.Footnote3
Stigma is a mark of social disgrace. It carries condemnation and ostracization by society and, typically, creates corresponding shame and isolation on the part of the stigmatized person.Footnote4 Stigma commonly impacts on the self-identity and self-esteem of drug users and addicts themselves [8] as well as presenting a psychological obstacle to seeking treatment [9]. It also has concrete practical consequences. In many parts of the world, drug addiction and drug convictions are formal barriers to healthcare, housing, benefits, employment, financial loans, and the right to vote; they may also result in long-term surveillance, forced labour, and torture and abuse during detention [10].Footnote5 Finally, although levels of drug use are relatively stable across different sectors of society, drug addiction and conviction rates are not equally distributed, but fall disproportionately on individuals who are otherwise vulnerable and disadvantaged, such as people who come from underprivileged socioeconomic backgrounds, have suffered from childhood abuse and adversity, struggle with mental health problems, or are members of minority ethnic groups or other groups subjected to prejudice and discrimination [10–16]. As a result, they bear a disproportionate share of the burden of the stigma and associated consequences surrounding drug use.
Why are drug users and addicts subjected to stigma and harsh treatment? No doubt a full explanation depends on a variety of complicated historical, socio-political and economic forces. But from an ideological perspective, we must also recognise how much these attitudes and policies resonate with the moral model of addiction which was dominant in the first half of the twentieth Century.
The moral model of addiction has two distinctive features. First, it views drug use as a choice, even for addicts. Second, it adopts a critical moral stance against this choice. Addicts are considered people of bad character with antisocial values: selfish and lazy, they supposedly value pleasure, idleness and escape above all else, and are willing to pursue these at any cost to themselves or others. In contemporary Western culture, we typically hold people responsible for actions if they have a choice and so could do otherwise, and we excuse people from responsibility if they don’t. Because the moral model of addiction sees drug use as a choice, it views addicts as responsible; because it condemns this choice, it views them as to blame – potentially deserving of the stigma and harsh treatment they in fact receive. For this reason, in so far as the moral model continues to influence – whether implicitly or explicitly – conceptions of drug use and drug addiction, the prejudice and injustices to which drug users and addicts are subjected around the world may appear justifiable.
For those who recoil from the attitudes embodied in the moral model, the disease model of addiction can appear by contrast to offer a desperately needed ideological corrective. Our concept of disease is not precise, and may well have different meanings and implications in different contexts of use [17]. However, with respect to models of addiction, the meaning and implication is relatively clear: “When addiction specialists say that addiction is a disease, they mean that drug use has become involuntary” [18]. According to the disease model, addiction is a chronic, relapsing neurobiological disease characterised by compulsive use despite negative consequences. Repeated drug use is supposed to change the brain so as to render the desire for drugs irresistible: the disease model maintains that addicts literally cannot help using drugs and have no choice over consumption. Compulsion can serve to explain why addicts persist in using despite the harm their use causes: if they could stop using, they would – but they can’t, so they don’t [19, 20]. But, as a result, it also removes responsibility and with it the potential for blame. The disease model of addiction can therefore serve to combat any apparent legitimacy that the stigma and harsh treatment of drug addicts might otherwise be perceived to have.Footnote6 With the pernicious influence of the moral model of addiction in the background, the disease model emerges as a call for compassion and a force for social justice and good.Footnote7
Strikingly, Marc Lewis rejects both a choice model and a disease model, offering instead what he calls a learning model of addiction. In his view, a choice model invites and offers to legitimate a critical moral stance: “Unfortunately, the choice model provides a convenient platform for those who consider addicts indulgent and selfish. If addiction is a choice, they reason, then addicts are deliberately inflicting harm on themselves and, more seriously, on others” [21]. But a disease model fares no better according to Lewis, for it wrongly pathologizes both the brain and the person. It wrongly pathologizes the brain because, in his view, the brain changes caused by repeated drug use are not evidence of pathology but of neuroplasticity: a part of the ordinary process of learning and habit formation that occurs when the brain is exposed to reward. It wrongly pathologizes the person because most addicts do not think of themselves as having a disease. Nor would it be good for them were they to do so: self-conceiving as a helpless victim of a disease and adopting the “sick role” [22] risks placing addicts in a position whereby they view themselves as dependent on medical and associated professionals for a “cure”.Footnote8 Yet, as Lewis emphasises, the personal experience and stories of the majority of people who have overcome their addiction to whatever degree typically involve a sense of agency and empowerment, alongside the fashioning and enacting of a life narrative that makes sense of the past while telling the story of a different future [21, 24, 25]. Crudely, addicts must come to want different things and to make different choices to overcome their addiction. Anything that helps with this task – pharmacological interventions that reduce cravings or stabilise patterns of consumption enabling gradual, monitored reduction; peer support and a sense of belonging; education and employment opportunities; the support of friends and family; books, hobbies, new pleasures; cognitive and psychological therapy; contingency management treatment; narrative self-understanding – should be used. But, to borrow a phrase from Lewis, addiction is “uncannily normal” through and through [21] – not a disease requiring specialised medical treatment, but a product of ordinary learning and development which can be overcome through further learning and development, in the form of personal growth and self-understanding.
I agree with Lewis that addiction is not a disease – at least given the typical meaning and implications of that concept. I am also sceptical that, given the state of our current understanding and evidence, we are justified in maintaining that the brain changes caused by repeated drug use are correctly classified as pathological. And I believe Lewis is correct to emphasise the central importance of a sense of agency, empowerment, and personal growth and self-understanding, in overcoming addiction. But I do not agree that we must reject a choice model of addiction.
There are two straightforward reasons why. The first is that the evidence is ever-increasing that, however hard it is for addicts to control their use, and however important it is for others to recognize and respect this struggle, addicts are not in fact compelled to use but have choice over their consumption in many circumstances. To briefly review some of this evidence: Anecdotal and first-person reports abound of addicts (including those with a DSM-based diagnosis of dependence) going “cold turkey” [13, 18]. Large-scale epidemiological studies demonstrate that the majority of addicts “mature out” without clinical intervention in their late twenties and early thirties, as the responsibilities and opportunities of adulthood, such as parenthood and employment, increase [13, 16, 26, 27]. Rates of use are cost-sensitive: indeed, some addicts choose to undergo withdrawal in order to decrease tolerance, thereby reducing the cost of future use [28]. There is increasing evidence that Contingency Management treatment improves abstinence and treatment-compliance, compared to standard forms of treatment such as counselling and cognitive-behavioural therapy, by offering a reward structure of alternative goods, such as modest monetary incentives and small prizes, on condition that addicts produce clean urine samples [29]. Experimental studies show that, when offered a choice between taking drugs or receiving money then and there in the laboratory setting, addicts will frequently choose money over drugs [30, 31]. Finally, since Bruce Alexander’s seminal experiment “Rat Park” first intimated that something similar might be true of rats [32, 33], animal research on addiction has convincingly demonstrated that, although the majority of cocaine-addicted rats will escalate self-administration, sometimes to the point of death, if no alternative goods are available, they will by contrast forego cocaine and choose alternative goods, such as saccharin or same-sex snuggling, if available [34, 35].Footnote9 In short, the evidence is strong that drug use in addiction is not involuntary: addicts are responsive to incentives and so have choice and a degree of control over their consumption in a great many circumstances.Footnote10
The second reason to maintain a choice model of addiction is that the process of overcoming addiction through a sense of agency, empowerment, and personal growth and self-understanding – a process that Lewis describes in The Biology of Desire [21] with great care and acuity – itself presupposes that addicts have choice and a degree of control. Agency needs to exist to be mobilized: you can only decide to quit and do what it takes to stop using and change how you live and the kind of person you are if you have some choice and control over your use and your identity. The “uncannily normal” road away from addiction is paved by ordinary moments in life where choices are made, resolve is hardened, and reflection and narrative is used to understand and buttress them. Of course, not all interventions that help addicts make changes involve choice – many things will always lie outside of our control – but choice and cognate psychological processes are nonetheless crucial elements in most if not all accounts of life changes that flow from personal growth and self-understanding, and it can be important and indeed empowering for this to be recognized and acknowledged [21, 37–39].Footnote11
Recall that the moral model of addiction has two features. It views drug use as a choice. And it adopts a critical moral stance against this choice. Because of the evidence that addicts respond to incentives and the role of choice and cognate psychological processes that involve agency in overcoming addiction, I believe we must accept the first feature. But that does not mean we must also accept the second. Just as addicts have choices with respect to drug use, we have choices with respect to how we respond to people who use drugs. In what follows, I offer a framework that can help us interrogate our own attitudes and responses, so that we can better see how to acknowledge the truth about choice in addiction, while maintaining care, compassion and a commitment to social justice and good. The framework derives from philosophical reflection on my personal experience working with patients whose behaviour causes them and others harm. The key is to better distinguish our concept of responsibility from our concept of blame, so that we can acknowledge agency and with it responsibility, without thereby immediately inviting let alone legitimating stigma and blame.