Addiction Treatment History
By Geoff Thompson, MA, CCC
In previous writing I commented on three narratives of drug use that arose in the past: moral, physical, and spiritual. The moral narrative was one of depravity, describing the user as one who forgets God, family and community, or his own well-being. The physical narrative was one of infirmity, describing the user as suffering from disorder or disease. The spiritual narrative was uplifting. Opium, alcohol, nepenthe, and cannabis were the means to transcend privation and suffering and live life, if only while intoxicated, at a more magnificent level.
In the post-prohibition era, our modern map of chemical dependency and treatment, which seems at first glace merely a conflicting and haphazard guide, is, in fact, the latest evolution of these narratives. Let’s have a look at the main models and approaches that make up our map.
The arrival of Alcoholics Anonymous (AA) in the late 1930s altered dramatically how we interpret chemical dependency and treatment. Founder Bill Wilson brilliantly conceptualized alcoholism in a way that was acceptable to scientists and moralists.
Wilson was open to professional medical help. He invited physician William Silkworth to contribute material to AA’s textbook (1939/2001), popularly known as the Big Book. Attempting to synthesize the polar views that chemical dependency was either physical or psychological, Silkworth proposed that it was both. The alcoholic suffered not only from an obsession to drink, but also from an “allergy” (p. xxvi) to alcohol. The allergic reaction provided a physical explanation for why alcoholics experience drunkenness in a qualitatively different way than non-alcoholics do, a condition that alcoholics, themselves, had long observed. Wilson happily borrowed the medical opinion that alcoholism was an allergic ‘disease’, but he was a businessman, not a scientist. His description of ‘disease’ in the Big Book was metaphorical, not technical.
Yet, in another of those strange events that permeate the chemical dependency field, AA—a bunch of alcoholics—became associated with the ‘disease’ model. Likely, this was the result of the medical professions’ endorsement. The 1951 Lasker Award of the American Public Health Association was, for example, presented to AA, and the citation read, in part: “In emphasizing alcoholism as an illness, the social stigma associated with this condition is being blotted out…” (Alcoholics Anonymous, 1939/2001, p. 573). Three decades later, the 1983 President’s Service Medal (now the President’s Community Volunteer Award) was awarded to AA, praising founders Bill Wilson and Bob Smith for “helping each other to overcome the disease.” Today, the curious notion that AA is responsible for the disease conception still persists in the popular mind.
The thinking of the 12-step program is also steeped in the prohibitionist attitude. Total sobriety is the aim; a single drink is a relapse into active chemical dependency. In part, this belief is derived from religious moral views, and AA was influenced by the very small, conservative-Christian Oxford Group. But the social influence of prohibition is also evident. AA was developed in the 1930s within the sphere of New England Puritanism (self-control, duty to God, responsibility as head of the family, productive work, moderation in all things), by a group of middle-class, middle-age, Caucasian men. Wilson was also keenly aware of the importance of anonymity for AA members. Decades of marches and pamphlets championed by the Woman’s Christian Temperance Union and Anti-Saloon League had stigmatized the drunk. Alcoholism may have been a medical condition, according to AA, but anonymity was a necessary protection against society’s shaming finger.
Popular understanding of AA ends here: alcoholism is a ‘disease’, and AA offers a mutual support group. The public has little understanding of the change agent involved—and little interest. The drunk was the Other, and as long as he was out of sight at his 12-step meetings and not drinking, then AA was wonderful, whatever it was doing. Even today, the public (and many professionals) sees AA mainly as one more healthy-minded coping mechanism for the addict, like relapse prevention skills or relaxation training or anger management courses.
But the AA program is more sophisticated. Strangely enough, and in spite of public perception, AA’s change agent evolved from the spiritual narrative. AA was the creation solely of addicts, and, likely, because of this, its conceptualization of chemical dependency is much closer to the Romantics, who also had intimate experience with mind-altering substances, and to William James. James (1902/1999) had declared that drunkenness was a variety of religious experience, encouraging Wilson to interpret the alcoholic as a fellow who was searching for religion in a bottle. Carl Jung affirmed Wilson’s thinking. Jung’s understanding was that the alcoholic’s thirst for booze was his thirst for wholeness. In a letter to Wilson, Jung argued that only a “spiritual conversion” could save the alcoholic. In fact he gave Wilson the cure for alcoholism: “spiritus contra spiritum” (Jung & Wilson, 1996, p. 4). According to Jung, only spirituality was powerful enough to overcome alcoholic spirits. Wilson emphasized this point in the Big Book: alcoholism may be a disease, but only “a spiritual experience [can] conquer” it (1939/2001, p. 44).
The solution to alcoholism was, therefore, obvious: provide the alcoholic with a more salutary route to spirituality. And this route lay in overcoming separateness. According to AA, the alcoholic’s essential problem is not excessive drinking, but self-centeredness: “Selfishness—self-centeredness! This, we think, is the root of our troubles” (1939/2001, p. 62). Believing that one is the center of the universe pushes away others and God. And in his blind pursuit of drunkenness, the alcoholic forgets himself. The 12 steps are, essentially, a series of activities that helps the alcoholic become self-aware (steps 4, 5, and 10), regain connections with others (steps 8, 9, and 12), and strengthen the relationship with a personal higher power (steps 2, 3, and 11). These connections take time and practice, but, according to AA, they lead to serenity and peace of mind. AA’s spiritual’ principles are the very qualities needed to achieve these connections: humility, honesty, forgiveness, gratitude, acceptance, and so on.
AA’s remarkable influence is understandable when one considers that the science of chemical dependency had done little to help the addict. Psychiatrist Harry Tiebout (1944) lamented that he had worked with an alcoholic woman without success. Desperate, he gave her a copy of the Big Book, and after attending a single AA meeting she never drank again. When Hazelden Treatment Center in Minnesota was searching for a method of professional treatment, it relied on the 12-step model, to which it then tacked on medical, psychological, and religious appendages.
AA’s influence also explains why chemical dependency workers have not been forced to complete formal training at a level demanded for mental health workers. Irvin Yalom’s attitude toward working with addicts is typical:
I have occasionally attempted to treat alcoholics in therapy groups composed of patients with a wide variety of problems, and like most group therapists, I have ended up discouraged, resolving each time to leave alcoholics to Alcoholics Anonymous” (1998, p. 117).
Today, physicians continue to promote AA and other 12-step programs to their addicted patients, courts mandate attendance at 12-step meetings, and most treatment programs require 12-step participation.
Developed at Wilmar State Hospital, the Veterans Administration, and Hazelden Treatment Center, all in Minnesota, what became known in the 1960s as the Minnesota Model is the main form of treatment in North America. Lemanski (2001) reported research that the Minnesota Model has become the basis of 96 percent of all treatments in the United States, though it has been variously modified since its beginnings in 1949. The most common form of the model takes the first five steps of the 12-step program and tacks on medical, psychological, and, often, religious components. In its original form, it was intended as a residential program, though it has now been applied in outpatient settings. The change agent in the model is actually the 12-step program, and clients are required to attend meetings during and after treatment.
It should be emphasized that the Minnesota Model is not the 12-step program; it is professional treatment (though confusing the two is, unfortunately, all too common). Recent disciples of the updated Minnesota Model at Hazelden have defended it against scientific attack, arguing that researchers have unfairly labeled it ‘coercive’ and not client-centered (see, for example, Owen, 2000). Given this, however, the vast majority of professional treatment based on the model pays little attention to the individual client. Staff members assume the roll of experts and tell clients what they must do to recover. Staff members decide who is sufficiently motivated to enter treatment, routinely discharge clients for not showing motivation (on average, the discharge rate is about 40 percent, though some studies argue that it is much higher), and determine what constitutes successful treatment. The counseling style is often confrontational because clients are in ‘denial’ of their problem, and since ‘denial’ is a Freudian defensive coping mechanism then the addict is labeled with a pathological personality trait. All this fits neatly with the 12-step program, which asks members to complete a “moral inventory” of themselves and discover their “defects of character.”
Like Freudian psychoanalysis, the Minnesota Model assumes a theoretical framework, into which it stuffs the individual. And like the traditional medical doctor treating a broken arm or diabetes, it treats the pathology of ‘chemical dependency’ and the ‘addict’, not a whole, complicated human being who happens to have a drug problem. Today, scholarly studies published on 12-step based treatment, including work at Hazelden Treatment Center, continue to assume the model’s theoretical orientation in their research designs.
According to the model, chemical dependency is a primary and overwhelming condition, over which the addict is powerless: she cannot be herself, cannot follow her values, cannot make choices. Among other implications, this means that addicts must ‘hit bottom’ before they are sufficiently motivated to ask for help. Every Hollywood movie that deals with chemical dependency treatment reaffirms this thinking. And it reminds us of the ‘demon rum’ and ‘witches’ brew’, a form of possession in which the addict is rendered helpless. And like the possessed, the addict needs someone to take control of the situation. The judge in Robert Downey, Jr.’s televised sentencing—after the actor relapsed yet again—made it clear that sending Downey to jail was not merely a legal obligation, but a moral one. Since Downey was powerless, he needed a sober and wise figure to guide him. (Interestingly, Downey’s attorney was Robert Shapiro, whose son’s death from an overdose convinced Shapiro that chemical dependency was a medical condition, not a moral one. Asked by the judge how many chances the court should give Downey before sending him to jail, Shapiro replied, “As many as it takes.”)
Twelve-step facilitation (TSF)
Another version of the model intended for outpatient settings is known as twelve-step facilitation (TSF). TSF differs from the Minnesota Model on several points. It is manual driven, designed for one-on-one counseling over three or four months, and does not see the ideal counselor as someone in recovery.
But it is similar to the Minnesota Model in that it is based on the 12-step program, and relies on the step program as the agent of change.
Chemical dependency science had a rebirth after the repeal of prohibition in 1933, and the foremost exponent of the new medicine was Elvin Morton Jellinek. Jellinek championed a scientific perspective of alcoholism that later scientists, such as George Vaillant at Harvard, would continue. Medical detoxification facilities sprang up in the 1950s as healthcare professionals realized that chemical dependency required specialized services. The early medical model essentially argued that certain substances caused chemical dependency. The alcoholic was the person who drank enough alcohol enough times that he became dependent, and the defining feature of chemical dependency was withdrawal.
Although this dated conceptualization remains popular today, neuroscience research in the 1990s, the ‘decade of the brain’, has moved chemical dependency science to a new level. Neuroscientist James Kalat (2003) reported research that confirmed that chemical dependency is not in the drug but in the person. Nora Volkow, head of the National Institute of Drug Abuse, was quoted in the October 10, 2005, issue of US Today as saying that “Everyone given an opiate…will become physically dependent, but not everybody will become an addict.” The chemical substance has no magical power; there is something in the individual person that makes that person vulnerable to drug dependence. Neuroscience thus supports the view that the addict is different from 90 percent of the population, because she suffers from a neurobiological predisposition to chemical dependency.
In our scientific and technological society, it is no surprise that that chemical dependency science has gained tremendous status. All professional healthcare organizations agree that chemical dependency has a physical substrate in the brain. The American Society of Addiction Medicine (2001) and its Canadian counterpart are convinced that chemical dependency is an epidemiological disorder. The American Psychiatric Association (DSM-IV-TR, 2000) classifies chemical dependency with schizophrenia, bipolar, depression, and other mood disorders. The American Psychological Association and the Canadian Psychological Association each describes chemical dependency as a mental health concern. Even the Canadian Human Rights Act defines chemical dependency is a medical disability.
Much of the impetus for publicizing the physical basis for chemical dependency is a response to the moral view, which dismissed the addict as sinner or reprobate. The benefit of the new science is that it encourages addicts to seek medical help and counseling, rather than promote incarceration. But the two views share a similarity: both conceptualize chemical dependency as a pathological condition. The patient may not suffer from a moral defectiveness, but she does suffer from a disease or disorder, which requires fixing.
The growth of scientific psychology in the twentieth century has led to a primary roll in treatment. Behaviorism and cognitive-behaviorism were applied to chemical dependency treatment as they gained ascendancy as schools of psychology. Later schools, such as motivation and family systems, added their contributions. The major psychology-based models of treatment are relapse prevention and motivational therapy, and, most recently, family therapy.
As various as the schools are, they, too, share the idea that excessive and illicit drug use is pathological. Chemical dependency is characterized as a maladaptive coping skill, warped thinking, lack of awareness of what the drug is doing, response to a dysfunctional family, and other deficiencies.
It is worthwhile to note that fiscal reality has forced us into the era of managed health, and healthcare insurance companies typically place spending caps on chemical dependency treatment. This has spawned a number of ‘brief therapies’ that can be accomplished within the insurance budget, such as motivational enhancement therapy. Therapy, under managed care, is often limited to solving a specific problem, encouraging the addict to consider a life free from drugs, and learning new skills. Minnesota Congressman Jim Ramstad has recently sponsored a new bill encouraging healthcare insurance companies to take a more positive attitude toward chemical dependency treatment.
Criminalizing of chemical dependency and the culture of consumerism: The new secular morality
Shakespeare’s secular worldview saw drunkenness as interrupting the natural order of things. The modern view is dominated by government legislation, and legal prohibitions on the sale and use of specific drugs has influenced treatment. Several drugs were regulated with the Harrison Narcotic Act in 1914, including cocaine and heroin. After the failed experiment of prohibition (1918 in Canada, 1920 in the US), governments also took over the control and regulation of alcohol, as well as drugs that were previously applauded as medically therapeutic, such as amphetamines. By the 1960s, governments effectively outlawed research into the efficacy of hallucinogens to combat alcoholism, stressed tight controls on pharmacotherapy for opiate addicts, and made the non-medical sale and use of these substances almost a guarantee of going to prison.
The criminalization of chemical dependency means that most addicts now have involvement with the criminal justice system, and the correctional system has often put pressure on evidence-based practice. Maple Ridge Treatment Centre in British Columbia, for example, has a contract with the federal correctional service, which everyone agrees is a wonderful opportunity. Demands of corrections often conflict, however, with our therapeutic approach. Clinicians and clients struggle openly to make sense of our policies of harm reduction and self-determination for clients whose lives are controlled by the government and who are sent back to prison for a slip. Corrections has a strong moral attitude. Marlatt (1998, p. 75) describes the infamous Glenochil jail incident in Glasgow. An outbreak of HIV at the jail spurred various authorities to offer inmates an amnesty day during which they could hand over needles without penalty. Many did offer up the needles, but, of course, many did not. The result was that inmates in active chemical dependency were now using far fewer needles, thus increasing the risk of infection. More recently, British psychiatrist Dalrymple (2006) argued that crime and chemical dependency go hand-in-hand, and addicts do not need treatment. He dismisses De Quincey and the Romantics as “grandiose, self-pitying, exhibitionist, grotesquely self-important, and complacent in its assessment of the significance of the writer’s own experience” (p. 82).
The new morality has also created a cynicism that equates chemical dependency as one more worthless product of our consumer age. Social commentators on the culture of consumerism have pointed out similarities between drugs and other hedonistic products (Boon, 2002). The economist Becker (Becker & Murphy, 1988) even used economic theory to come to terms with chemical dependency. He argued that addicts using drugs can be understood in terms of any consumer of a commodity. And the addict-writer William S. Burroughs had some fun with the idea in his novel Naked Lunch.
The introduction of what has become known as the ‘harm reduction’ approach to treatment has catalyzed the passion of the various players in the chemical dependency field. Unlike abstinence approaches, it invites addicts into the map-making, asking them what they want in the recovery process. Harm reduction thus confronts those who see the addict as Other. Marlatt (1998) interprets harm reduction precisely as an evidence-based alternative to the coercive moral and medical models.
Although harm reduction treatments regularly make it to the front pages of newspapers—needle exchanges, safe injection sites, safe smoking sites, providing heroin to heroin addicts or wine to alcoholics—harm reduction is a complex and sophisticated approach to chemical dependency treatment. Unlike, for instance, the Minnesota Model, which developed out of the 12-step program, harm reduction has its origins in research. Because of this, most evidence-based treatment programs prefer it; in fact, almost all scholarly outcome studies today measure success in terms of reduced harm, not abstinence. The evidence base has led many authorities to approve the new approach. In Canada, for example, all federal and provincial government policies on chemical dependency treatment follow harm reduction.
Harm reduction is based on a post-modern epistemology and argues that therapists must meet the client where the client is at and not require an arbitrary level of motivation dictated by what the clinician decides is appropriate. Harm reduction is also concerned with reducing harm to families and to society, which is a much broader focus than traditional treatments, which focus almost exclusively on the addict. Perhaps its most controversial aspect is that it does not demand complete abstinence as a prerequisite for treatment. Clients are accepted for treatment even if they are on prescribed mood-altering substances, and clients are not discharged from treatment for relapsing; in fact, harm reduction sees relapse as a normal part of the recovery process (though not a necessary stage). Treatment under harm reduction uses various techniques to motivate clients through the process of recovery.
North America borrowed harm reduction from European models, in response to the growing incidence of HIV/AIDS and other diseases. But other than this goal of reducing the spread of infections, the North American version of harm reduction is vague and confused. And it is a hard sell in a setting that promotes a ‘war’ on drugs, is steeped in the 12-step program, and which continues to rely on prohibition as the answer to chemical dependency. Most harm reduction enthusiasts have made concessions, suggesting that the ultimate goal remains abstinence, even if the method of getting there differs. And most agree that the addict is defective in one way or another.
Harm reduction asks addicts what treatment would benefit them. It takes away the coercion and judgment of traditional treatment, saying that the addict should be consulted and respected. The invitation encouraged drug users to break their silence and voice their views, not to cower before the moral thunder and medical diagnosis.
They had spoken up in the nineteenth century, with Thomas De Quincey’s Confessions of an English Opium Eater, Charles Baudelaire’s Artificial Paradises, and others, but the presses of the twentieth century churned out thousands of pages exploring the drug experience from every angle: William S. Burroughs, Charles Bukowski, Aldous Huxley, Jack Kerouac, Malcolm Lowry, William Styron, Dylan Thomas, Hunter S. Thompson, etc, etc. Nobel laureates William Faulkner, F. Scott Fitzgerald, Ernest Hemingway, and Eugene O’Neill soaked their lives and works in booze.
These works described transcendent experiences, the yearning for community, thinking out of the box, freeing the repressed imagination, and a feeling of connection with the universe. Of course, the prolonged use of drugs could lead to perdition. Even here, however, chemical dependency may be held up as a refusal to embrace vapid middle-class mores and values. Henry Chinaski in Barfly, Charles Bukowski’s autobiographical account of his drinking life in Los Angeles, returns to the bar as the only means to reclaim his identity and individuality. Other accounts held that drugs were a vehicle to satisfy the natural yearning for becoming self-aware, connecting with others and nature, and feeling at one with the cosmos.
It is puzzling and remarkable that there have been almost no commentaries from mainstream experts on these aesthetic expressions of the drug experience. Dalrymple (2006) may have dismissed the Romantic opium eaters as self-absorbed inebriates, but he is strangely silent on modern writers who describe the drug-induced altered-state-of-consciousness with at least as much enthusiasm. In fact, the few thinkers who have paid public attention to the ideas of these writers use them mainly as footnotes offering a color commentary on their scientific views.
The descriptions are usually not systematic and rarely scientific; but they are often elegant and passionate, unlike the dry works in peer-reviewed journals and textbooks. It may be that these addict-writers have caused an uneasiness: we know that passion and ecstasy do not exist easily in our scientific society. Or perhaps it is because modern drug-using writers cannot be so easily dismissed by critics such as Dalrymple. They examined the drug experience beyond the Romantics’ creed that focused on a deeply emotional and enriching experience of the inner self. Yet each of these artistic geniuses noted that drugs could help the user discover a transcendence in his sober life. And many of the modern writers do not glorify the drug experience. Charles Bukowski, John O’Brien, Evelyn Lau, and other popular fiction writers described the addict’s life as a struggle against existential concerns.
Or—and what may be most uncomfortable—is that a serious examination of these works would force is to rethink our moral and scientific narratives.
Not just artists are involved in the spiritual narrative. Psychologists interviewed addicts about the drug-induced altered-state-of-consciousness, and then published factor analysis, phenomenological, and narrative studies. Trujillo (2003) offers us a typical description from a cocaine addict: “My mind just opens tremendously….I feel life is wonderful. I can do anything” (p. 171). The famous Canadian Royal Commission into the use of non-medical drugs interviewed 350 experts, including many drug users, to discover what was going on with the young people of the 1960s. The commissioner concluded that the positive experiences of drug use “bear a striking similarity to traditional religious values”: a concern with the inner self, an “emphasis on openness and the closely knit community,” and “identification with something larger, something to which one belongs as part of the human race” (Le Dain, 1971, para 331).
We can now make some sense of our modern map of chemical dependency and recovery. Take the example of Vancouver’s safe injection site. This site is supervised by government workers and funded by the taxpayer; at the same time the law declares it is a criminal act to possess cocaine, heroin, and so on. But this contradiction is easily understandable by applying our narratives. Prohibitionists—with their moral narrative—are disgusted by the initiative; harm reduction advocates—who have invited addicts into designing the treatment process and rely on research evidence—welcome it. Similarly, the moral narrative sees substitution therapy (prescribing methadone to heroin addicts, for example) as irresponsible, but the scientific narrative sees it as a valuable treatment.
Our modern map has taken the moral, scientific, and spiritual narratives to a more sophisticated level. And, in doing so, the borderlands between the three themes are often blurred. Under the modern idea that chemical dependency and recovery are bio-psycho-social (and some add spiritual) phenomena, the modern map has begun integrating the different perspectives. Evidence-based treatments often provide medical support and dietary counseling, family programs, relapse prevention training, and explorations into faulty thinking that hinders recovery. Many programs now offer a spiritual component, though these are far from being mainstream and the nature of their ‘spirituality’ is often vague and confused.
But our efforts at integration are preliminary and fragmented. Essentially, they paste together various approaches and techniques without any overarching design that provides a big picture.
And what is particularly noticeable is that we have not addressed with any substance the relationship between chemical dependency and disconnection, which our historical survey showed is the dynamic that gives rise to our passionate views on drug use. We have not listened deeply to Alexander (2001) when he tells us that chemical dependency is a response to a lack of psychosocial integration or to Peele (2004), who sees chemical dependency in context of the human condition. The addict’s view that drugs satisfy a natural yearning for transcendence is not taken seriously, in public at least, although the silence of scholars on the works of the great addict-writers is somewhat perplexing. We have focused on the superficial level of disorder or maladaptive coping skills, and we spend a great deal of energy debating the merits of abstinence versus harm reduction. Those who adhere to the scientific narrative struggle to believe that forgiveness and love could have tangible impact on recovery. Those who adhere to the moral narrative applaud television shows, such as Intervention, which affirm that addicts are out of their minds and need fixing.
Despite the addicts’ struggle to feel a sense of belonging in society, we continue to ascribe an Otherness them, even in recovery. The demand for ‘anonymity’ in AA and the Minnesota Model, the assumption that excessive and illicit drug use is morally wrong, the labeling of chemical dependency as ‘maladaptive’, ‘chronic disease’, ‘medical disability’, and so on betray our view that there is some defectiveness in the drug user. The struggle of harm reduction to find a place in this stigmatized world is evidence of how strongly we hold on to the old thinking. Several thinkers have abandoned the drug field precisely because they felt ostracized by this dominant thinking (for eg, Alexander, 2004; Weil, 1998). Others refused to publish research that did not condemn drug use per se until a more favorable political climate was in place (for eg, Lensen, 1999), and still others felt the need to publish under pseudonyms (for eg, Hastings, 1970).
In the next article, I’ll focus on the two dominant approaches to chemical dependency treatment: abstinence and harm reduction. The introduction of harm reduction is a sign that the landscape is changing, moving away from the moral narrative and toward the scientific.
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