In search of synthesis for positive and negative liberty and addiction

In a recent post, I highlighted a schism in advocacy efforts related to addiction.

On one end we see advocacy focused on non-interference in drug use, and various levels of facilitation of less risky drug use. These efforts largely emphasize negative liberty, or “freedom from” interference in living one’s life as one chooses.

On the other end, we see advocacy to establish civil (as opposed to criminal) pathways to involuntary treatment. Many of these efforts emanate from family members’ concerns about the capacity of an addicted family member to care for themselves, or that they might be a danger to themselves or others. These efforts emphasize what we might call impaired positive liberty, or “freedom to” pursue a life organized around their goals and values because of an illness (addiction) that causes intermittent impairment of decision-making and behavioral self-control.

One of Recovery Review’s contributors described a recent conversation about positive liberty and the limited autonomy people with addiction experience. It was suggested that it’s gaslighting to question whether the person with addiction really knows what they want. Gaslighting is a real risk. My previous post mentioned the risks of paternalism and abuse.

AND, we risk gaslighting people with addiction and their families if we frame addictive drug use, its consequences, and symptoms as manifestations of autonomy. We risk gaslighting if we fail to recognize that addiction is a disorder that involves intermittent involuntary and overwhelming wanting (craving), and impaired behavioral self-control (compulsion) leading to AOD use in ways that result in functional impairment and serious consequences for the person with addiction and their loved ones.

In that post, I included this graphic from the book Critical Incidents to illustrate the risks associated with both underinvolvement (hands-off) and overinvolvement (hands-on).

All of this invites questions about whether we have to choose between positive liberty or negative liberty and, if not, how we might develop synthesis around these seemingly incompatible priorities.

It’s important to acknowledge that, for many years, most of the field was too indifferent to infringement of the negative freedoms of people who use drugs, including people with addiction.

Regarding interventions focused on positive freedom, in my previous post, I did not comment on the merits of these involuntary treatment plans, but I did validate the realities animating these impulses and efforts by families and communities.

I am skeptical about these involuntary treatment efforts for a few reasons. First, there is a risk of a slippery slope of sacrificing personal freedoms and dignity (negative liberty) in hopes of enhancing positive liberty. There’s also the possibility that action will be taken in the name of positive liberty that is really just about the interests of others. This concern could be mitigated by a rigorous process to protect the rights of people with addiction, similar to the processes for involuntary mental health treatment. Second, to justify temporarily limiting a person’s rights, we’d need to have confidence that it offers a meaningful opportunity to facilitate remission or safely navigate a high-risk period to a low-risk period. In mental health systems, these periods of involuntary treatment are typically days, occasionally weeks, and, in relatively rare cases, longer. It’s hard to imagine that a treatment episode lasting days, or even weeks, could meaningfully impact the kinds of risks that might prompt a petition for involuntary treatment. After all, we had a system organized around acute care models and finally began to recognize the failure of those models around the turn of the millennium.

Fortunately, there’s a lot of distance between a neutral and non-interfering stance and coerced treatment.

Developing approaches that respect negative freedoms and enhance positive freedoms will probably require reconnecting with some old, hard-learned lessons.

One prerequisite is the recognition of addiction as an illness that’s associated with significant bio-psycho-social-spiritual functional impairment and is characterized by symptoms that often interfere with problem recognition, behavioral control, and motivation to recover.

This highlights the positive liberty challenges presented by addiction. The 2011 ASAM definition of addiction does a good job describing the salient features of the illness.

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.

American Society of Addiction Medicine: Definition of Addiction (2011 version)

Another barrier to synthesis is the failure to differentiate between addiction and other drug use. The emphasis on Substance Use Disorders as a spectrum and people who use drugs (PWUD) often results in the conflation of addiction with other drug problems and drug use.

Clarity on this matter can help highlight where positive liberty is not an issue.

Brian Coon has directed our attention to “the big 5” SUD criteria as a useful strategy for differentiating severe SUDs from other AOD problems.

Question: Which DSM criteria for SUD are found primarily in severe SUD’s?

Answer: Efforts to control/cut down but unable (rule setting), Craving with compulsion to use, Failure to fulfill role obligations, Activities given up or reduced, Withdrawal.

That is to say, in his sample, the presence of any one of these 5 criteria, separately, was more likely than not to be present among 6 or more total positive SUD criteria for any one individual.

Coon, B. (2022, January 27). A Fresh Look at “The Big 5” Substance Use Disorder Criteria

Third, we might be well-served by rediscovering what Bill White identified as the theoretical foundation of addiction counseling. These four defining premises establish addiction as a primary disorder associated with other bio-psycho-social-spiritual problems often requiring help from professionals with specialized knowledge of both addiction and recovery.

1) severe and persistent alcohol and other drug problems constitute a primary disorder rather than a superficial symptom of underlying problems

2) the multiple life problems experienced by AOD-impacted individuals can be resolved only within the framework of recovery initiation and maintenance

3) many individuals with high problem complexity (biological vulnerability, high severity, co-morbidity) and low “recovery capital” (internal assets, family and social support) are unable to achieve stable recovery without professional assistance, and

4) professional assistance is best provided by individuals with special knowledge and expertise in facilitating the physical, psychological, socio-cultural and often spiritual journey from addiction to recovery.

White, W. (2004). The historical essence of addiction counseling. Counselor, 5(3), 43-48.

To say that addiction is a primary disease and not caused by these other problems does not imply that these problems are unimportant, or that they have no relationship to addiction. These other problems may be secondary to addiction, or they may also be a co-occurring primary problem. In either case, these problems may affect the risk for addiction, the onset, its course, severity, and response to treatment. They may represent a barrier to recovery. And, importantly, they cause suffering.

The interaction of problem complexity and recovery capital helps explain why some people recover from addiction with no professional assistance and others require extensive long-term professional support.

Importantly, these premises also provide an endpoint for interventions — physical, psychological, social, and spiritual recovery. Identifying this endpoint doesn’t imply coercion or a one-size-fits-all approach, just as a cancer endpoint of full remission doesn’t imply coercion or a one-size-fits-all approach.

Finally, it’s important to recognize that in many ways, in many places, addiction counseling lost its way or failed to live up to its ideals of acceptance, dignity, understanding, compassion, and love.

What is this attitude that I call the key to successful [alcoholism] treatment? First, it is accepting of the other person just as he is, for exactly what he is. Second, it accords him the dignity of his humanity quite apart from his illness which may have buried that humanity deep out of sight. He is regarded as a person, in great trouble to be sure, but not a non-person for all that. Third, it offers him understanding and, as a result of that, compassion, or as many recovered alcoholics flatly put it, love. Finally, and perhaps most important of all, it exhibits faith, a belief that he too, this alcoholic whoever he may be, can and will recover.

Marty Mann, 1973, Attitude: Key to successful treatment. In: Staub, G. and Kent, L., Eds. The Para-Professional in the Treatment of Alcoholism. Springfield: Illinois: Charles C. Thomas Publisher

Somewhere along the way, the interactions between people with addiction and addiction treatment providers began to bear a growing resemblance to the failed systems that addiction counseling was intended to remedy. (Possibly parallel process? From contact with those systems, contact with distressed clients and families, working in poorly designed and underfunded systems, and vicarious trauma?)

[Too many professionals are] condemning, and therefore often hostile. They are quick to blame the alcoholic for his condition and to see the horrors of the condition as the man. They unwittingly treat him as less than human because he is not as they are. They are contemptuous of his weakness, his failure to stand up to life. They are sometimes punitive, believing that what he really needs is to be taught a lesson. They do not understand him and so they do not really like him. And he knows it….The first requirement for successful counseling of the alcoholic is the correct attitude….If you don’t have this, then it doesn’t matter how many techniques you use, they aren’t going to work.

Marty Mann, 1973, Attitude: Key to successful treatment. In: Staub, G. and Kent, L., Eds. The Para-Professional in the Treatment of Alcoholism. Springfield: Illinois: Charles C. Thomas Publisher

Finally (and critically) we need to acknowledge that addiction counseling became too indifferent, passive, and, in many cases, complicit in the criminalization, stigmatization, and control of people who use drugs. (Reasonable people can disagree about the options for the legal status of drugs, but there can be no doubt that people who use drugs were stigmatized and incarcerated in ways that were unjust and indefensible.)

Further, this presented a conflict of interest. The field grew to rely on external motivation and coercion into treatment, from courts, families, and employers, failing to develop strategies and programs that would voluntarily attract and engage those patients before they reached the point of a third party coercing them.

Successfully navigating these challenges will require a commitment to not repeating these failings along with safeguards to help prevent drift. An important approach to those safeguards would likely be power sharing arrangements.

Is synthesis possible?

As we reflect on the positive and negative freedom challenges related to addiction and drug use, none of this tells us exactly what synthesis looks like. But, if we accept that there are a lot of options between a neutral and non-interfering stance and coerced treatment, we can start with the premises identified here:

  • Addiction is a treatable illness characterized by episodes of impaired behavioral control, decision-making, problem recognition, and motivation to recover. This combination of symptoms means that passively waiting for the patient to choose treatment and recovery can constitute neglect.
  • Most AOD use is not addiction and failure to distinguish between addiction and other drug problems establishes the conditions for inappropriate care.
    • Their conflation can mistake freely chosen drug use for the impaired control of addiction.
    • Conversely, their conflation can mistake the vicious cycle and misery of addiction for freely chosen behavior.
  • The historical roots of addiction counseling point us to the following lessons:
    • Addiction is a primary illness, though other primary and secondary problems may obscure this.
    • Addiction and its associated problems can only be resolved through recovery initiation and maintenance.
    • The interaction of problem complexity and recovery capital results in wide variation in treatment needs and treatment response.
    • Specialized knowledge of addiction and recovery are required to facilitate recovery.
  • Helping relationships (at the provider and system levels) should be based on acceptance, dignity, understanding, compassion, and love.
  • Even professions and systems animated by acceptance, dignity, understanding, compassion, and love — even those emerging in response to the failures of other systems to demonstrate those attributes — can fall into patterns of neglect, abuse, control, stigmatization, and exploitation.
    • A sign of a sick system is the reliance on the use of coercion to get patients into care.
    • A sign of a healthy system is the capacity to voluntarily attract patients into care.

Vigilance is required to maintain commitment to attention to all of these factors. If it’s true that ongoing vigilance is required, is synthesis possible? Or, is this a problem that can’t be “solved”, requiring us to maintain awareness of and attention to the tension between competing truths and values?

And, of course, if positive liberty is limited by addiction, an essential measure of any system of care is how successful it is in facilitating liberation by initiating and maintaining recovery.

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