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).

Myth of the brain disease model of addiction

images2The brain disease model of addiction is one of the most prevailing myths in our understanding of addiction. It is indubitable that addiction has a significant neurological component, but to reduce addition to neurophysiology is a gross error. The reason this way of thinking is so readily accepted is that it is congruent with the prevailing scientific materialistic worldview that dominates most analysis of addiction, and human behavior. Although many adherents of the brain disease model acknowledge the interplay of psychosocial factors with physiology, they nonetheless place primary emphasis on biology. Below is will briefly try and point out that viewing addiction as a brain disease is making an error in assigning addiction an ontological status, that is not befitting of its true complexity.

Integral scholar Sean Esbjörn-Hargens (2010) describes that the ontic status of a phenomena can be understood as having three potential orders of complexity, “the first order is characterized by phenomena that we can more or less ‘see’ with our own senses. The second order is the result of using various extensions of our senses (instruments, computer programs, charts) to see the phenomena … The third order cannot be seen with our senses nor indirectly by our instruments, but only by indications” (p. 159). Certain phenomena can be adequate accounted for when viewed as a first or second order ontological complexity, but certain phenomena has to be understood as a third order complexity, to avoid running the risk of developing over-simplified and reductionist understanding of the phenomenon.

At the highest level of abstraction lies the notion of an individual’s addiction-in-the-world, which is a staggeringly complex phenomenon beyond our senses or instruments. So addiction “is two steps removed from our direct experience (the first order) and our perception of it relies on many abstract indicators (the second order), which are epistemologically distant and ontologically complex” (Esbjörn-Hargens, 2010, p. 159). Therefore is best viewed as a “probability continuum” of ontological complexity, co-arising and enacted through different methodologies and worldviews. For example, a first order ontology could be the experience of being high on the drug. It is available to our senses. A second order ontology could be the pharmacological effect of a drug on neurotransmitter levels or unconscious psychological drives as risk factors to substance abuse. This we can understand only through measurement and calculations, and through a metapsychological perspective. Both these approaches can grasp only partial aspects of human existence.

When understanding addiction as a third order ontology, we begin to understand why certain models of addictions, especially the single-factor models, give rise to such partial and reductionist explanations. They are good at explaining certain “archaic features” of addiction in the realm of its enacted first or second order ontology, but methodologically and epistemologically, they are incapable of enacting addiction on a third order ontology. Technically, a third order ontology is actually the level of ontological complexity where the notion of addiction exists (a first or second order ontology cannot articulate a complex phenomenon like addiction, and can only enact “archaic-addiction” probabilities).
Most of the models of addiction have as their foundation a worldview of scientific materialism and positivistic methodology that are typically adequate for exploring phenomena existing on the first and second order of ontological complexity. However, such models are hopelessly inadequate in explaining complex phenomena such as addiction (or any human behaviour) which “exist” on the third order of ontological complexity. For example, reward deficiency syndrome (Blum, 1995) can only be understood as one of many possible physiological risks that interact with other aspects of being human, without having to reduce human behaviour and motivation to neurotransmitter levels. Simply put, even though an addict has abnormal neurotransmitter levels, at the molecular realm of brain physiology concepts such as addiction are meaningless. To talk at molecular level about addiction is like saying that an amoeba, which only primarily exists in a primitive level of ontological complexity, has abandonment issues originating from poor object relations.

Medard Boss (1983) points out that the natural scientific method has its limitations in explaining the human realm, as it originated from and is only sovereign in the non-human realm (natural sciences). Boss’s approach of Daseinsanalysis, based on Heidegger’s (1962/1927) ontology, could be described as an ontic “articulation of Heidegger’s” ontology. In our current context we could say that by using Heidegger’s method in exploring psychology and psychiatry, Boss echoes the dangers of explaining higher-order complex phenomenon (which includes any aspect of human-being-in-the-world) by using methodology (i.e. empirical observation) and epistemology (i.e. positivistic) dominant in lower orders of complexity. He believes that in Freud’s metapsychology (and most other theory of human existence) there is inevitably an abstraction and tapering from our lived engagement in-the-world (human-being-in-the-world reduced to first and second order ontology).

In summary: the phenomenon of addiction is best understood as a third order ontology, which can only be co-enacted (“brought-forth-in-the-world”) when juxtaposed with associated “methodological variety” and “epistemological depth” (Esbjörn-Hargens, 2010). The notion of epistemological distance highlights that some facts of addiction “speak louder” than others and some elements of addiction facts are only enacted within certain worldviews. Methodological variety refers to the fact that “the more epistemological distance and ontological complexity increase, the more methodological variety will increase. Thus, the more multiple an object becomes (the What), the more methods and disciplines you will need to study and make sense of it (the How), and the more perspectives there will be on what is or is not the nature of that object (the Who)” (Esbjörn-Hargens, 2010, p. 162). In short, trying to reduce any human’s being-in-the-world to a first or second order ontology, as the “brain disease” model tries to do, is fundamentally flawed. Addiction is caused by, affects and manifests in all areas of our being-in-the-world, and only paradigms (or rather meta-paradigms) that function on this level of ontological complexity may suffice, if we are ever to understand, and successfully treat this colossal nemesis.

References to this blog post can be found in my articles as indicated on my Publications and Research page of my website www.guyduplessis.com.