Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction by Maia Szalavitz

Author:Maia Szalavitz [Szalavitz, Maia]
Language: eng
Format: epub
ISBN: 9780738285764
Google: dZjZzQEACAAJ
Publisher: Hachette Books
Published: 2021-11-15T00:15:58.911523+00:00

AS DENNING LEARNED MORE ABOUT ADDICTION TREATMENT, SHE CONTINUED to be outraged by the lack of scientific justification for its practices and the harmful nature of so many of them. Nearly all of the programs she visited and read or heard about from attendees were utterly blind to ethical considerations around power. It was as if someone had read Michel Foucault’s Discipline and Punish: The Birth of the Prison and decided to use the panopticon as a clinician’s guide to the treatment milieu—or chose to copy the brutal tactics that appeared among the “guards” in the Stanford Prison Experiment as a model for therapy. Absolute power on the part of the treatment program and complete obedience by patients were simply assumed to be acceptable and appropriate—with little room for disagreement, rare or difficult access to any reliable form of complaint procedure, and no recognition of how frequently unchecked power leads to abuse and atrocities. The increasing rejection of paternalism seen in general medicine was almost nowhere to be found here.

While this was most extreme in therapeutic communities, it wasn’t limited to them. In many medication and Minnesota Model/twelve-step programs, clients are frequently and repeatedly told to “shut up and listen.” (One saying: “Take the cotton out of your ears and put it in your mouth.”) Even programs with the most caring, gentle reputations—which would never allow anything as extreme as attack therapy—are still likely, even now, to have counselors who “joke” that every time their patients’ lips move, they are lying.

Obviously, all of this conflicts with harm reduction ideas of “meeting people where they are” and following their lead as they set their own goals. The Minnesota Model and harm reduction clash not just because the former has only one acceptable goal for patients, but also because the twelve-step view of complete “powerlessness” during active addiction is falsified by the demonstrable progress toward health seen in programs like needle exchange. Confrontational therapeutic communities are clearly incompatible, too: breaking people down emotionally in order to rebuild their personalities cannot be reconciled with patient dignity and autonomy and has been shown to be harmful.

Even medication treatment, which is potentially philosophically harmonious with harm reduction, is often problematic in practice. For example, clients practicing harm reduction by, say, using marijuana instead of cocaine, can be expelled from medication treatment for opioid addiction, since they are not completely abstinent. Such a policy is clearly not compatible with harm reduction because it both imposes goals on patients—rather than meeting them where they are—and increases their risk of death.

None of this is to say that these approaches can’t be modified to be more congruent and evidence-based, simply that they typically aren’t. Many people within harm reduction have found twelve-step programs useful—including me. The real problem is claiming that one approach is the only way and contains the only truth about addiction—rather than, as one twelve-step slogan has it, telling people to “take what you like and leave the rest.”

In light of this messy and frequently hostile treatment field, harm reductionists faced an enormous challenge.

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