Substance Abuse Treatment: Maintaining the Status Quo?

My dissertation research will focus on following women who misuse prescription drugs as they undergo substance abuse treatment in rural Central Appalachia. I have certainly found that lack of access to treatment is an issue in my preliminary research, but the substance abuse treatment system itself also proves problematic. Through the literature on substance abuse treatment and my own fieldwork in Central Appalachia, I suggest that substance abuse treatment programs, especially those for women, help maintain the status quo both outside of and within the programs themselves through specific characterizations of treatment program clients as individuals who are personally responsible for their addiction. I look forward to further parsing out the relationship between substance abuse treatment and social control mechanisms in my dissertation research.

Radcliffe and Stevens (2008:1006) argue that the institution of substance abuse treatment is rooted in the neoliberal ideals of personal responsibility because “The notion of addiction is only meaningful in a culture where the self-control of individuals is valued above all.” Erica Prussing (2007) claims that treatment in the United States in particular is based on an Anglo-American middle-class Protestant culture that emphasizes self-control, individualism, and personal testimony. Treatment programs are focused on remaking the individual from someone who exposes their body to drugs to an individual who is controlled, responsible, and who has a “universal body…living in a uniform but nontoxic environment” (Hunt and Barker 1999:128). 

Treatment programs aim to make individuals into so-called “normal” rather than “pathological” citizens and through this transformation divorce clients from their environments and the marginalized statuses they may have based on class, race, gender, and drug use (Hunt and Barker 1999; Skoll 1992; Zigon 2010). For example, people who I interviewed who have been through treatment programs for prescription drug misuse in Central Appalachia complain that the treatment program staff expect their clients to instantaneously turn into middle-class citizens and ignore the barriers clients face in trying to undergo this metamorphosis, from living in an area that has few job opportunities that pay a living wage to being stigmatized as a drug felon and essentially barred from employment.

I am particularly interested in how treatment programs characterize women who use drugs. Although I could not find any recent literature that explores how women are framed in treatment programs, anthropologists and feminists argue that women who use drugs are more stigmatized by the public, media, and policy makers than men who use drugs in the US (see Bourgois and Schonberg 2009; Reagan 2010; Roberts 1997). Casting women who use drugs as “bad” is tied to the perceived relationship between women, particularly mothers, and children (Flavin and Paltrow 2010; Goodwin 2011; Whiteford and Vitucci 1997). The relationship between fathers and their children is generally not emphasized. For example, most women who enter emergency departments because of drug-related issues are asked about their children and whether or not they are pregnant, while men are not questioned about their children (Chavkin and Breitbart 1997). 

In my own experience, I am continuously surprised when I tell someone about my proposed dissertation work and they exclaim, “Oh, the poor children!” I am left shocked as I wonder how I can frame my research as focusing on women’s health and their access to health care, not how women’s health affects their children. Ortiz and Briggs (2003) and Springer (2010) argue that characterizing women who use drugs as “bad” fits perfectly into neoliberalism, where personal responsibility and individual moral failure are highlighted in order to relieve society of accountability for poverty, inequality, racism, and other social ills. In a neoliberal system, women’s drug use is framed as making them not only “bad” women and mothers, but also “bad” citizens who make selfish choices that hurt the health of the society at large by supposedly harming children’s health (Craven 2005; Goodwin 2011; Whiteford and Vitucci 1997).

Skoll (1992) argues that treatment programs’ individualized goals emphasizing personal responsibility and self-control prevent group solidarity, neglect radical discourses associated with rights movements, and thereby prevent treatment programs from challenging the status quo of a society that marginalizes segments of the population. Programs that focus on remaking the individual may not address women’s most basic concerns, do not change the environment in which women must live, and ignore the association of drug use with the feminization of poverty and homelessness (Chavkin and Breitbart 1997; Sun 2007; Zigon 2010). For instance, women were frustrated with a prison-based substance abuse treatment program because it did not address their need to find employment after imprisonment (Hall et al. 2001). Time that women were forced to spend in drug treatment actually impeded them from spending time in vocational training programs because treatment and vocational programs were scheduled concurrently (Hall et al. 2001). 

Differentiating between “good” and “bad” women and mothers allows treatment programs and society more generally to blame societal problems on the most marginalized women who are often impoverished, unemployed, facing violence, and dealing with poor health (Bourgois and Schonberg 2009; Goodwin 2011; Ortiz and Brigss 2003; Springer 2010). The media and policy makers blame drug-using women for giving birth to “damaged” babies, for overburdening the foster system, and for challenging traditional family structures as children are removed from homes (Ortiz and Briggs 2003; Springer 2010). Hall et al. (2001) and Radcliffe and Stevens (2008) argue that if treatment programs do not give women who misuse drugs vocational training, help with finding housing, and other social support in overcoming their underclass status, they may more easily fall back into their roles in informal drug economies, drug using networks, and communities where they used.

Women in Central Appalachia who I have spoken with said they are frustrated with substance abuse treatment because although they generally value counseling services at treatment facilities, they feel stuck in their environments. Women said that the treatment programs they have dealt with do not help in the search for jobs that pay a living wage, alternatives to abusive home environments, or legal services for criminal offenses. Women said they feel blamed by treatment staff if they relapse or break program rules. Although I have not interviewed staff in Central Appalachia, treatment program staff who I have spoken with from other US locales said they feel helpless in changing the environments in which their clients live. I in no way want to suggest in this paper that program staff are all powerful beings who can suddenly change their clients’ lives. However, perhaps there are issues that programs could address that would challenge the status quo where women who use drugs are marginalized or would mediate the structural violence that women who I have interviewed in Central Appalachia regularly face. I hope to explore this further in my dissertation research.

Treatment programs that emphasize self-control and personal responsibility may also prevent reforms of the treatment program system itself by labeling all client critiques as “denial” or by silencing clients who relapse. According to the outpatient treatment program for homeless women that Carr (2006) examined, “denial” is a primary component of addiction. Clients are supposedly in “denial” when they do not acknowledge that they have a problem with substance abuse or when they attribute any of their problems to anything other than their substance abuse (Carr 2006). Using this emblem of “denial,” treatment staff characterize all clients’ critiques of the program as the clients’ “denial” of the connection of their substance use with their problems (Carr 2006). Clients therefore have no way of critiquing the treatment program (Carr 2006). Programs that focus on remaking the individual and thus blame the individual for any transgressions may ignore structural properties of programs that impede clients’ success. 

If treatment programs are located in communities where women used to buy drugs, it may be harder for clients to commit to treatment when they can easily find a dealer they know (Hall et al. 2001; Nelson-Zlupko et al. 1996). In my experience interviewing women who have been through treatment, women said they feel blamed and defeated when they relapse or break program rules and therefore do not feel entitled to critique the aspects of the program that did not work for them. The emphasis on personal responsibility seems to be internalized by clients and thus effectively silences client critiques of the programs.

By emphasizing the neoliberal Anglo-American middle-class ideals of self-control, personal responsibility, and individualism (see Radcliffe and Stevens 2008; Prussing 2007), I suggest that substance abuse treatment programs in the US help maintain the status quo of the environment in which drug use takes place and the treatment program itself. I hope to further analyze the process through which treatment programs distort, silence, or even support clients’ critiques of social injustice in my dissertation research. I think this process will play a role in how successful clients understand treatment programs to be.

Lesly-Marie Buer

References

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