Incompatible Knots in Harm Reduction: Part 2 (Collectivism)

Harm reduction proponents often profess that their approach has ‘roots in humanitarianism and libertarianism’ (Newcombe 1992: 1), which place primary emphasis on individual liberty and individualism, yet there is also a tendency by many of them to adhere to social justice ideology (Pauly 2008; Friedman 1998; Graham 2014) which inherently favours collectivist values and epistemology. For example, groups like the Harm Reduction Coalition identify as a ‘movement for social justice’ (Greig & Kershnar 2002: 365). Social justice can be defined a position that aims for the eradication of all forms of social oppression, inequality and, frequently, for one form or other of economic redistribution (Feagin 2001). A harm reduction approach that is informed both by a collectivist value of a social justice orientation and the individualist values of libertarianism can become internally inconsistent.

There can be detrimental consequences when harm reduction policies are geared towards collectivist instead of individualist aims. The influence of social justice activists has moved the aim of harm reduction away from helping the individual towards that of the ‘common good’. Mugford (1993) points to the self-contradictory nature of harm reduction’s adherence to its utilitarianism (informed by collectivist values, through which Draconian anti-Drug strategies have been defended) and its liberal values (based on humanistic and libertarian perspectives, the protection of civil liberties and human rights). Miller’s (2001) view is that the primary impulses of harm reduction programmes have not been out of concern for the individual drug user, but rather for the benefit or protection of the ‘general public’ and the reduction of health care costs. Indeed, for some harm reduction organisations and activist groups, syringe exchange is merely a means to an end, a political activity and not a value-neutral healthcare intervention. In extreme cases, harm reduction threatens to become a ‘holy cause’, a kind of mirror to the moral righteousness behind the politics driving the ‘war against drugs’. As Eric Hoffer, author of The True Believer (1951) reminds us

The burning conviction that we have a holy duty toward others is often a way of attaching our drowning selves to a passing raft. What looks like giving a hand is often a holding on for dear life. Take away our holy duties and you leave our lives puny and meaningless. There is no doubt that in exchanging a self-centred for a selfless life we gain enormously in self-esteem. The vanity of the selfless, even those who practice utmost humility, is boundless (p. 23).

The bias of an overly collectivist approach to addiction is also exemplified in research, where nearly all attention has focused on indicators of change that are observable and socially desirable (e.g., abstaining from drugs, avoiding criminal activity, gainful employment). It frequently neglects other, more functional, indicators (e.g. quality of life, satisfaction with treatment) that bear more importance to drug users themselves (Fischer et al 2001). And, perhaps most crucially, rarely have studies explored the congruence of these outcomes with the perspectives of drug users (Fischer et al 2001). The currently available instruments (e.g. the generic Nottingham Health Profile) were developed for and by professionals without input from drug users or their families and caregivers (Fischer et al 2001). Their viewpoints are notably missing from the literature (Drumm et al 2003). According to Saleebey (1996: 301) oppressed or marginalised populations typically have ‘[their] stories buried under the forces of ignorance and stereotype.’ In the context of this essay, I would argue that drug users often have ‘their stories buried under the forces of ignorance and stereotype’ (Saleebey, 1996: 301) of collectivist thinking.

Harm reduction approaches should not be driven by political agendas, and we do not need more ‘true believers’. Social justice activism is a political project and not an evidence-based scientific activity, and it is concerning how social justice-orientated harm reduction proponents assume the self-evident truth of this position, considering the complex philosophical or political debates and critiques that underpin collectivist ideology (see Strang 1993, Psychoactive drugs and harm reduction: From faith to science). Instead, we require the perspectives of people who identify as addicts, empirical research, clinical experience, concern for drug users as individuals and pragmatic health aims.

References to be found in: Du Plessis, G. P. (in Press) Some Incompatible Knots in Harm Reduction, in Let’s Talk About Opioids and Harm Reduction in South Africa. HSRC Press (Edited Volume).

Incompatible Knots in Harm Reduction: Part 1 (Relativism)

Since the introduction of the harm reduction paradigm in the 1980s, it has almost universally been presented as the ‘self-evidently correct’ and ‘rational’ approach to the problems associated with drug use (Erickson 1995; Weatherburn 2009; Single 1995; Roe 2005). It frequently pits itself against recovery orientated paradigms, characterising them as punitive, narrow in perspective and ‘rooted in punitive law enforcement models and in medical and religious paternalism’ (Newcombe 1992: 1), or as undermining the freedom, dignity or positive self-image of individuals with substance use disorders (Ezard 2001; Zajdow 2005). Instead, harm reduction is often presented as a humane, value-neutral, pragmatic, and scientific alternative, and is, thus, often accepted uncritically as an obvious and unqualified good (Souleymanov & Allman 2016; Marlatt 1998).

Yet, harm reduction proponents are frequently ill-informed of some of the social and ontological assumptions that underlie their concepts. When these assumptions are accepted as ‘self-evident’, harm reduction can become beleaguered with internal inconsistencies and uncertainties in its core goal (Mugford 1993; Weatherburn 2009; Keane 2003). An internally contradictory position within harm reduction theory and practice can create a ‘double bind’, that results in what existential psychiatrist R. D. Laing (1960) refers to as an ‘incompatible knot’.

In the follow three blog posts, informed by critical hermeneutics (Roberge 2011; Ricoeur 1981, 1986; Gadamer 1975), I provide a brief critical evaluation of some of the foundational suppositions that often underlie harm reduction theories and interventions. I deliberately take on the ‘strong’ versions of these suppositions in order better to reveal what I consider to be at stake. I will limit my focus to three theoretical orientations (or ‘-isms’), often advanced by harm reduction proponents, which contribute to its ‘incompatible knots’. These are: 1) relativism, which leads to conflation of drug use and addiction as concepts and to conflation of ‘drugs’ in general; 2) collectivism, which prioritizes the common good over that of the individual; and 3) determinism, which represents people with addiction as victims with limited agency.

It is common for harm reduction proponents to conflate the behaviour of drug use and the condition of addiction (Davies 1997; Peralta & Jauk 2011), and to minimize the distinctions between medications commonly prescribed by the health care system and those (such as the opioids) that are diverted into non-medical economies for their intoxicant and dependency-producing properties. I will make a distinction between ‘categorical conflation’ and ‘continuum conflation’. Categorical conflation (which will be my focus here) can be considered as denying any categorical difference between drug use and addiction, whereas continuum conflation acknowledges some differences but assigns enough similarity to place it on an ontological continuum (The DSM-5’s (APA 2013) sub-categories of substance use disorders as mild, moderate or severe runs a risk of continuum conflation). I argue that both these types of conflation of drug use and addiction are serious conceptual errors that lead to deleterious consequences for the design and sustainability of harm reduction policy.

Comparing drug use to addiction is like ‘comparing apples and oranges’. Drug use and addiction are distinct phenomena and harm reduction interventions for drug use and addiction should be fundamentally different. Makings claims whether drug use is good or bad is a normative statement and stating whether someone is an addict or not (and how to treat it) is a descriptive or positive statement. This is similar argument to Hume’s law which states that we cannot derive normative statements (how we ought to act) from descriptive statements (what is) because there is a fundamental difference between how we should act morally and how the world factually is (Hume 1739). Addiction is not morally good or bad, it just is – it is a scientific concept, whether it is present or not is a descriptive/positive statement. Normative conflation of drug use and addiction returns us to a moral model of addiction (Pickard et al. 2015). This model applied a normative orientation to both drug use and addiction and concluded that both are moral failings and should be judged and treated accordingly (Mugford & Cohen, 1988). ‘The parallel would be with theorising alcohol usage in general on the basis of what is known about institutionalised alcoholics’ (Mugford & OMally 1999: 27)

One of the primary reasons that many harm reduction proponents conflate drug use and addiction is because they tend to have a have a relativist view of drug use and addiction, influenced by radical social constructionist perspectives (Dingelstad et al 1996; Davies 1997). ‘Strong’ social constructionism as a philosophical approach tends to suggest that “the natural world has a small or non-existent role in the construction of scientific knowledge’ (Collins 1981: 3). Applied here, it proposes that addiction exists as a dominant and historically produced narrative, which would cease to exist if we thought, wrote and spoke about it differently (Davies 1997). Weak social constructionism proposes that many of the concepts and approaches to addiction are socially constructed but concedes that there is an underlying reality to some of them, and is perhaps best defined as epistemological pluralism. Proponents of a social constructionist position call addiction a ‘myth’, a phenomenon that does not really ‘exist’ outside our collective perception and even that ‘drugs’ are social constructions (Davies 1997; Hammersley & Reid 2002). Jacque Derrida (1995), for example, concluded that ‘the concept of drugs is a non-scientific concept, that it is instituted on the basis of moral or political evaluations: it carries in itself norm or prohibition, and allows no possibility of description or certification…’ (p. 229). While (as other contributors to this volume have discussed) the concept of ‘drug’ carries ambiguities and social meanings that impact policy, the differing chemical nature of psychoactive substances and their potential bioactive consequences on a body and psyche must be recognised and respected.

Although there is a cornucopia of perspectives on addiction which makes a unified understanding a challenging prospect, it is nonetheless erroneous to deny the ontological realities of drug use and addiction through adopting an position of relativism. There are certainly ways to maintain epistemological plurality while not holding to a strictly realistic metaphysics. Adopting a form of critical or pragmatic realism (Harre & Moghaddam 2012; Bhaskar 1997) conceptualises addiction without submitting to judgemental relativism (giving equal voice or weight to multiple theories or interpretations). In the trenches of the therapist working with addicted populations, and parents who have addicted children, a radically relativist perspective of addiction has little value and purchase, and can even be harmful.

References to be found in: Du Plessis, G. P. (in Press) Some Incompatible Knots in Harm Reduction, in Let’s Talk About Opioids and Harm Reduction in South Africa. HSRC Press (Edited Volume).