Drug Abuse

Hidden themes: dominant discourses in the alcohol and other drug field

Michael J. Taleff *, Marguerite Babcock

Abstract

The alcohol and other drug (AOD) field has been dominated by a number of discourses. These are beliefs which have not been critically analyzed and are taken as common knowledge. Such beliefs are shown to have a detrimental effect on AOD therapy. The article outlines five such dominant discourses, and suggests interventions to counterbalance their effects, 1998 Elsevier Science BV. Drug Abuse & Addiction, Detoxification, Treatment, Opiate Withdrawal. Substance Abuse: Heroin, Cocaine, Marijuana, Crystal meth, Vicodin, OxyContin, Amphetamines, Percocet and others.
All Rights Reserved.

In her recent paper, Hare-Mustin (1994) spelled out what she considered to be a series of dominant discourses inherent in the field of therapy. They are defined as verbal exchange or conversation that carries a specific philosophy, and assumed to be supported by the power of reason. Fraser and Gordon (1994) define a discourse as doxa, or "the taken for granted common sense belief that escapes critical scrutiny". These beliefs sustain certain world views (Clifford, 1986), as well as support certain notions about things and people. They also marginalize and obscure other ways of seeing the world (Sands and Nuccio, 1992). Discourses often draw therapists unwittingly toward predetermined interpretations of their clients' behavior.

Most people rely on a modernist approach to discover the truth of things. This has been a predominant philosophy since the 17th century (Howe, 1994). Essentially, modernism insists that knowledge can be founded upon, or grounded in, some kind of' absolute truth. Knowledge, from this perception, is seen to be about things, objective and external to the knower (Lowe, 1991). This has been a significant and powerful force within Western history and provides its adherents with a sense of' security and order. Accordingly, the world can be understood through study and all phenomena can be reduced to a series of logical formulas. However. inherent in this approach is the tendency to form dominant discourses which tend to marginalize and disparage rival views.

There are competing discourses that circulate in our culture; "...some have a privileged and dominant influence on language, thought, and action" (Hare-Mustin, 1994). Various discourses not only influence everyday life, but also float around the therapy room without notice. They influence the direction of therapy we are supposed to objectively provide.

Traditional alcohol and other drug (AOD) theory and practice depend oil and uphold several dominant discourses. These are often presented as having a final certainty. Much of AOD therapy, in use today serves to stabilize the beliefs it has created. In the "therapy session proper, the conduct of these sessions will be as a mirrored room in which the conversation will only renect back what is voiced- (Hare-Mustin, 1994). Whatever dominant discourse exists in the room, its reflection will be the singular one that will define the parameters of the problem and treatment direction. Hare-Mustin (1994) writes that "The efforts of most therapists represent the interests and moral standards of tile dominant groups in society---. Therein lies the problem. The discourse is allowed to explain the dimensions of' a client, regardless of the client's reality.

We take a position of questioning such accepted beliefs. to discover the client's reality. The heart of' this questioning lies in a philosophical position called postmodernisrn. From this perspective, there is no one true theory of' reality. Rather there can be a series of rival views. The belie*f.s behind these views are no longer considered unchallengeable (Parry, 1993). This stance challenges all dominant discourses, no longer allowing them to be taken for- granted (Hare-Mustin, 1994).

l. Dominant discourses in AOD treatment

We have examined the literature, and have found at least five dominant themes in AOD work. These five discourses can be seen to operate in many AOD treatment programs, and are usually considered to be of a sacrosanct nature.

1. 1. Blame the client for treatment failure
It has been customary in AOD treatment to blame the client for treatment that fails. In terms of language, this comes across in phrases such as, 'he's still in denial', 'she didn't work the program', or 'he didn't hit bottom'. It is not usually recognized that the philosophy of' Alcoholics Anonymous (AA) reinforces this discourse. In the Big Book Alcoholics Anonymous (1976) there is a section that reads, "Rarely have we seen a person fail who has thoroughly followed our path. Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves". This passage clearly indicates that those who have tried and failed the AA program are themselves failures. Another indication of this discourse is evidenced at the end of' each meeting. The attending individuals often hold hands in a circle and say in unison, "it works, if you work it". The implication of' both statements is that the AA program is the path to recovery and if you. the individual, fail to follow the simple steps, it is you who has failed, not the program.

There is other, approved, AA literature that clearly states that the fellowship is not for everyone. When asked whether AA is the final truth on the issue of recovery from alcoholism, many in the fellowship will defer to this latter declaration. Yet, the first discourse noted above is often stated by the more dogmatic advocates of AA in a dominant manner.

The discourse of AA must be seen in a developmental sequence. At the time when AA was developed, in the mid1930's, nothing else was helping the alcoholic effectively. Now, however, there are a growing number of alternative approaches to the recovery process. Some are showing promise. Thus, the adage, 'rarely have we seen...' is a relative one, in that there are more strategies for recovery than were available 60 years ago. However, the dominance of the AA method often appears to still marginalize those new approaches. Kasl (1992) states, "AA attracts grateful disciples who forget the model is J List a model --a form and words put together by a human being. They forget that it is health, Lin-recovery, discovery, and healing that are sacred, not the words we use to get us there. Words are words. They are not truths. They are not holy". To those who hold tightly to the words, AA and the traditional offshoots are the truth. For example, Mueller and Ketcham (1987) state, "Surely, many alcoholics have been able to stay sober without AA, but that is not to say that they couldn't have used AA and benefited from it in their recovery". This statement implies that the recovery process that i~ attained without AA is not as good as the one found in AA. It is a marginalizing statement that is meant to undercut the validity of other roads to the recovery process.

Why, on the other hand, couldn't one say the opposite thing about those who have attained their recovery in AA? "Surely, many alcoholics have been able to stay sober with AA, but that is not to say that they couldn't have used Smart Recovery (or Secular Organization for Sobriety or psychoanalysis, etc.) and benefited from it in their recovery." In fact, the recent Project Match treatment outcome results supports this contention (Project Match Research Group, 1997).

This points to the powerful discourse that pervades the AOD field, that AA is the only true answer to recovery. A book entitled 'The 100 Best Drug and Alcohol Treatment Centers in the United States' (Sunshine and Wright, 19~8), indicated that the vast majority of these centers use a variation of the AA program for their core program philosophy. In fact, many of these programs consider AA attendance as mandatory.

Abiding by this dominant view, the treatment program never is Lit fault. It is always the client.. So, as much as traditional AOD treatment states that it is in the forefront of diminishing the stigmatizing of the addict via popular American disease model of addiction (you have a disease, not a moral shortcoming), in reality it is not. The traditional AOD professionals themselves blame the client for failing treatment. In doing this. they are in the grip of a dominant discourse and are suspect.

This is especially true in the realm of relapse. It' a relapse does occur, the traditional model proposes that the client has failed (Chiauzzi, 1991). The relapser is expected to inaugurate a recovery process from the beginning, as if this person, who may have attained 20 years of abstinence, knows nothing and is a novice at recovery. Chiauzzi (1991) notes, "In what other area of medical treatment is an outcome that falls short of perfection viewed as a failure?" In addition, this particular discourse effectively blocks any new creative means to deal with a relapse. This is the power and downfall of the dominant discourse.

A personal encounter illustrates this dominant discourse idea. In a recent conversation, a professor of a large university in the eastern USA managed to get around to styles of teaching AOD material. She indicated, with a sense of stern pride, that in her eyes AA was so important that she insisted her students attend at least three meetings in a semester, or fail her course. A program that was developed to invite people to participate was now used as one that was mandatory. This is dominant discourse at its most blatant.

The reader at this point can begin to see how language can be used to create a dominant discourse, regardless of the facts. That will have detrimental effects for the different and complex clients with very different needs in AOD treatment.

1.2. Blame the victim
A theme related to it's-the-client's-fault is that of victim blaming in addictions work. This attitude, often unwitting oil the part of AOD workers, assumes that whatever befalls any individual is that person's own fault. This indiscriminate approach has had some negative results in addictions treatment.

Probably the most blatant recent example of victim-blaming in this field has been the notion of I codependency' (Babcock and McKay, 1995). This concept blames the allegedly pathological personalities of the addicts' significant others for perpetuating the addiction. This personality profile of such family members has been repeatedly refuted in competent research. Also, such an analysis of the causation of the addict's behavior is overly simplistic. What causes an addicted person to behave in certain ways is determined by a number of factors: the addict's personality, cultural dictates, gender roles, the force of compulsion, etc. That is, 'codependency' is a bivariate analysis of the behavior (one variable influences a second variable), while research has shown the situation of' families with addiction histories to be multivariate, and multidirectional (many variables affect each other, in many different direction~,). Interpreting the addict's behavior as bivariate is most distinctly not critical thinking.

There has also been a recent spate of blaming addicted mothers for drug/alcohol-related birth defects (Babcock, 1995). Empathy for these mothers, who not only experience the ravages of addiction but also may have severely impaired infants, has only occasionally been expressed (Finkelstein et A., 1981; Raskin, 1992). Cicero (1994) and Babcock (1995) have outlined the multiple factors creating these birth defects. That contrasts with the simplistic cause usually cited for these defects, that of the mother's drug/alcohol use (again, a bivariate analysis). But this mother-blaming fitted well into the villainizing of (especially minority) addicted mothers in the 1990's, which amounted to a simplistic attack on a powerless target. Corse et al. (1995) write of' the 'they lie' attitude of drug/alcohol staff toward addicted mothers, and the negative impact this has on treatment.

The blaming of the client for addictions treatment failure, mentioned in the previous section, is also a blaming-the-victim phenomenon. It is far simpler (and less threatening) for us to blame clients than to critically examine the complex environmental factors feeding into their problems, or to critique the possible shortcomings of our treatment provisions.

In essence, victim-blaming is simplistic, feeds into many different stereotypes (sexism, racism, etc.), and is not menacing to the addictions worker's self-image. It also seriously fails us in our attempts to provide effective treatment for our clients.

How can we change our thinking? For example, can we admit that it is perhaps the gaps in our therapeutic skills that create and/or engage resistance in our clients (Taleff, 1994)? Can we begin to appreciate the multiplicity of external factors that shape the behaviors of families struggling with addiction in their midst (Orford, 1992)? Can we realize that the problems causing difficulties for children of addicted parents are multifold and .complex, and can never be reduced to just 'bad mother(ing)' (Harrison, 1991)?

We also need to be critical of whose agendum we are serving when we blame victims in our addictions work. Is it actually helping our clients, or is it helping the welfare of the gurus who preach the fiction that reality is simple? Truly thinking our way through these questions is crucial to promoting optimal treatment for the difficult disorder of addiction.

1.3. Closeness equals pathology

It has been shown that Western psychology/ psychiatry, including addictions counseling, views the notion of closeness as sickness (Brown and Ballou, 1992; Babcock and McKay, 1995). Within this viewpoint, there has been little discussion of the value, indeed even the social necessity, of mutual dependence.

For example, Gestalt theory discusses the negatives of 'confluence', doing what others want you to do. Bowenian family therapy theory portrays 'lack of differentiation' as a problem. Gagnier and Robertiello (1991) note that "in the Freudian system needing people was eschewed as a symptom of immaturity and developmental failure". And the recently popular term 'codependency' in addictions work criticizes an 'over focus on others'. However, such ideas do not critique the problems that are actually very pressing for our current society-those of over-distancing and of seeing others as objects to be manipulated.

What does this fear of closeness have to do with our work on family patterns in addiction? Such work is usually (unwittingly) influenced by systems theory. This theory proposes that all family members are involved on an equal basis in the dynamics of the family, and that each 'family symptom' involves covert if not overt conspiracy of all members. That is, 'you get what you ask for' (Bernal and Ysern, 1986). Systems theory, although never having been validated as an accurate analysis of what goes on in families, has been accepted almost as gospel by most family therapy workers. Adherents of the idea of codependency similarly claim that significant others of addicts/ alcoholics are 'too closely' involved in the dynamics of' the addiction, allegedly to the point of' conspiring in the continuation of the 'addicted family system' due to their own complementary pathology.

So what we have done when subscribing to the notion of codependency in analyzing family patterns is to blame family members for the ongoing addiction. We assess their closeness to, overprotectiveness of. and worry about the very ill addicted member, and somehow come to the conclusion that the family is to blame. 'Enabling' is not seen as an understandable fumbling in coping, as a desperate attempt to try to save the addict from self-destruction. but as a morbid tactic to help the addict continue the addiction. From this viewpoint, love, anxiety, cultural closeness, and feminine nurturing are all ignored (Inclan and Hernandez, 1992). Orford (1992), by contrast, has given us poignant description,,, based on decades of family research, of families' painful struggles when addiction is in their midst.

Feeding into this phobia of closeness, we engage in simplistic reasoning which produces blaming and villainizing. This also produces bivariate rather than the more accurate multivariate analyses of what we see. Blaming and simplifying do damage the work we do with our clients.

What are we to do to correct this trend'? First, we need to understand the phenomenon of closeness. It is a reality of human social life, for which we are hardwired from birth. As clinicians, we must learn to distinguish between normal human interdependency versus the few cases of pathological dependency. Gagnier and Robertiello (1991) write, "People need people. Life (is) not just about gratifying impulses. Life (is) about connecting with people."

Krestan and Bepko (1990) similarly evaluate the notion of codependency, writing that it "promotes the false belief in the value of total independence and autonomy and fails to recognize the need for healthy interdependence."

That is, humans (certainly including our clients) are complex. As Gagmer and Robertiello (1991) point out, not all gradations of dependency can be subsumed under the simple label of pathology. Instead, we must be willing to critically think, to carefully consider what best describes each client, without resorting to stereotypes. For example, the review of Orford (1992) should be read to understand the subtleties of what families undergo in struggling to preserve the closeness of family ties, when faced with the addiction of' one of their members. There is no excuse for us not to carefully and thoughtfully explore the phenomena before us.

1.4. Too much knowledge is bad (don't think, it will get You into trouble)
This dominant discourse has its roots in the old argument which states, 'in order to understand, you have to be one'. According to this view, knowledge of the addictive process gained in anything other than real experience is considered null and void. Often, the rational voice of responsible research is discounted. This discourse is especially aimed at any kind of higher education. There is a modicum of truth in this particular discourse. Not long ago, medicine and psychiatry did not effectively treat the chronic chemical dependent. There were numerous relapses and frequent failures. All kinds of strategies were attempted, and most demonstrated little if any sustained success.

With all their education, the 'professionals' could not seem to crack the problem of alcoholism. It took the efforts of a few lay people who got together in an Ohio town in the mid- I 930's to develop a fellowship that showed promise. In this case that fellowship was AA, and it was founded by the very people that science could not help, alcoholics. That remains a powerful discourse in AOD treatment 60 years later. The message continues to be that they, the professionals, couldn't help us then, or now.

However, professionals have made significant improvements in their craft of helping AOD clients. Therapeutic approaches for the AOD dependent range from the learning- cognitive realms to the humanistic existential, to those postmodern approaches called solution/brief and narrative therapy. Today, there is no one approach that is head and shoulders above any other treatment method (Institute of' Medicine, 1990).

Yet, the mentality of' 'You have to be one to understand it' persists. Kaminer (1992) has indicated that many who subscribe to this idea turn to sell'-help books. These readers seek pat answers, formulas and guarantees, not inquiry and investigation. She further writes that the same group "ill often turn to talk shows for their guidance. Ms Kammer has appeared on several such programs and has observed others. She notes that the audience and guests are more interested in exchanging testimony than they are in the exchange of facts, research and data. 'Don't think' remains the message. Many AOD workers come from these ranks.

Built on this don't-think attitude is the historical and dominant strategy of applying simple slogans as front-line treatment interventions in AOD. Many who take this position consider the lay founders of AA to have discovered the real, workable strategies for the recovery process. These individuals claim the program is simple, with simple steps and key simple statements about recovery. Examples of the statements include 'one day at a time', 'turn it over', and 'keep it simple. stupid'. Such statements are considered to be the preferred treatment strategy of many treatment centers across the country. No need for elaborate theories to explain the addictive process., and no need for the education that accompanies such theorizing. The result is a discourse that mistrusts and disparages higher education. The gap between the complexity of professional research and the simplistics of addictions treatment has been documented (Ogborne, 1988; Gomberg, 19K Brown, 1991; Babcock, 1992)

The traditional answer to addiction treatment then is: don't think, don't drink (or use), and go to meetings. That answer has an intuitive sweet sound to it, but this cannot always do adequate justice to the complexity of problems that have been discovered about addicts (Lowinson et aL, 1992). That kind of complexity requires extensive education and far more sophisticated thinking than simple aphorisms can provide (Taleff, 1996; Taleff and Martin, 1996). If simplistics are the only answer professionals use in their treatment to address addiction, there will continue to be many problems and relapses. Chiauzzi and LiIjegren (1993) write about the avoidance of "taboo topics in addiction treatment", topics that are avoided due to the difficulties inherent in complexity. We do a disservice to our clients by not creating and discovering other means and methods of helping-many others than just the dominant discourse of simplistics.

1.5. Never trust the client (all addicts are cons and manipulators)
There is a very old joke that goes, 'How can you tell an alcoholic is lying' Answer, 'His lips are moving.' In a derogatory manner, this joke is meant to demonstrate that addicts have a common personality, one peppered with defects, imperfections and flaws. Above all, this alcoholic personality is one never to be trusted (Taleff, 1994; Corse et aL, 1995).

This dominant discourse states that you can't trust addicts, because they are cons and manipulators. They are always plotting and thinking of ways to beat the system, or delude themselves in order to get another drink or drug. That thinking is considered the 'stinkin' type. This 'stinkin thinkin' is considered a chronic means which the addict uses to get over, and is also considered to be implicit in the addict's character.

Treatment stall' who harbor such an attitude toward the client will create an atmosphere that is not conducive to positive treatment. Wallace (1991) notes that caregivers I negative attitudes toward their addictions patients may well be perceived by the patients, resulting in a "closing up and avoiding the sharing of' information needed for a thorough assessment". A negative attitude is exhibited in the patient rules and regulations AOD treatment centers feel they need. Many of these rules include no calls Lind no visits in the first weeks of treatment. The new patient is then handed a copy of the program's schedule, which if not followed, will result in discharge. In addition, there is a search of the patient's luggage.

To many people this looks like a shake-down. In fact, it is. The reason behind the shake-down is the powerful influence of the dominant discourse, which indicates all addicts are not to be trusted.

The staff of these treatment centers believe that it' they did not have this approach, the patients would be calling people to get drugs into the program, trying to secure rides out of the facility, or continuing their drug business while in treatment. This is not to say these things haven't happened. But, if a tabulation of checked suitcases, phone calls and visits were ever made, the frequency of smuggled drugs, calls for rides, or illicit lousiness would probably be low. There is a perception that the addicted personality needs structure before the true recovery process can begin, and it's up to the facility to provide this. What in fact is created is an atmosphere of mistrust between the newly arriving patient and the wanting-to-be-trusted staff.

Once in the program, stories of the patient getting a 6first step prep' or it drug using history thrown back in his or her face. because it wasn't good enough, or it was considered bullshit, is common. It is a treatment approach in which the addict is seen as needing to be shown that he or she can't get over on the staff. The end product of this persistent approach is the hardnosed counselor who takes no crap, and is confrontive at the slightest sign of' resistance. This is considered the best model.

If this is the dominant discourse the AOD professional brings into the therapy room, a problematic tone will be set for the entire session. This discourse is enhanced by the human fact that "stereotypes are notoriously difficult to change", as Kunda and Oleson (1995) have confirmed in their research.

It is interesting to note that as new approaches to treating the patient with AOD problems arise, many in the dominant group are quick to criticize them. In this era when new ideas are rapidly making their way into AOD treatment, criticisms abound. For example, the preeminent criticism is, 'You don't understand. I have worked with these types of individuals and my experience tells ine they are not to be trusted.' Whenever that line of 'reasoning' is used, you can be sure it is a dominant discourse talking, rather than critical thinking.

2. Hidden themes and implications for treatment

If the AOD counselor walks into a treatment session with one or all of these dominant discourses imbedded in his/her thinking, that session will be biased. The dominant discourse, whatever it is, will not allow any other viewpoint into the counseling room. This would be as a mirrored room, reflecting back only what is voiced in it (Hare-Mustin, 1994).

In a broader sense, the effect on society can be the same. A dominant idea can be so strong that it is difficult to see beyond its implications, to introduce fresh ideas. People become slaves to a dominant discourse and consider it the truth. It is here the society becomes dangerous. For example, the notion of drug use as a legal problem has taken such a dominant hold in our culture that it is difficult to have other productive assessments of the problem heard.

An additional by-product of these dominant discourses is that they infantilize the receiver of the discourse. They do this because the discourse says, 'Believe in me and nothing else. What you think is irrelevant. 1, the dominant discourse, have cornered the truth. Obey, or be banished from my sacred realm.'

The recommendation of Hare-Mustin (1994) to offset this problem is to become reflectively aware. This means developing a special vision that challenges dominant assumptions, versus mindlessly going along with them.

How does one achieve this special vision'? Sagan (1995) would say that we need to have access to a 'baloney detection kit'. In it, is an array of tools for reasoned arguments to recognize fallacious arguments. We have taken aspects of 'the kit', and combined them with an outlined series of ideas to improve judgment accuracy and reduce clinical bias (Spengler et at., 1995). then modified these ideas somewhat, and adapted to them to the AOD field, The recommendations include:

1. Increasing a counselor's openness and curiosity. For the AOD counselor, this means keeping the mental self in good shape by constantly reading, and upgrading counseling skills via an ongoing educational process. This includes fostering a sense of curiosity, and moving away from uncritically accepting statements, to asking all varieties of questions.

2. Summon multiple assumptions about an issue or person at hand. That means checking ideas that support Your ideas, as well as those that don't. For AOD counselors, this means learning not to be smug about any inference they make about a client or AOD concept. Counselors must go out of their way to find other explanations that challenge a set of propositions about a client or clinical theory. In fact, feeling smug should be a warning that you are not looking at all sides of' an idea. It' possible try to confirm an assumption with an independent viewpoint.

3. Use high-grade empirical data that is not only of' the quantitative, but also of the qualitative variety. This means becoming familiar with the research literature. That, in turn, means having a fundamental understanding of' research design and statistics. For example, the idea is to not guess about effectiveness of a particular treatment format, but be able to base assumptions on data that support a certain position. Try not to rely too heavily on authorities. They have been wrong in the past and will be wrong in the future.

4. Delay judgments, especially those that judge 'on sight'. Snap judgments prove nothing even if they are 'respected' by many in the AOD field. Essentially, the on-sight judgment is one that has not taken any time to develop. It indicates that the advocate of the judgment was more likely to be in the grip of a dominant discourse.

5. Reduce overconfidence and attachment to any one AOD idea or theory. Any one idea that is applied to all the manifestations of humans is stereotyping of the highest order. The thinking AOD counselor is aware of this, and is willing to consider two or more ideas, even if they are conflicting. This conflict has the double advantage of spawning a heightened sense of curiosity, and of generating potentially important questions.

6. Use cognitively complex approaches to client interpretation. Simple answers that attempt to answer the complex questions of addiction theory and addiction treatment are wrong. Thinking AOD counselors have at their disposal any number of more sophisticated ideas and strategies to match the best possible treatment to the needs of a specific individual.

These steps, as well as any you can create, can serve as a foundation of self-reflection and recognition, to avoid the powerful five dominant discourses that have plagued the AOD field.

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