Illicit drug use: a new approach to intervention.

Hudson, Susan

Is it time to rethink the way we perceive the use of illicit substances? For those coerced into 'treatment' for their illicit substance use via the justice system, it may feel long overdue. The article presented here explores the possible link between empowerment and illicit substance use for the legally coerced population with possible implications for practice. With some preliminary findings from interviews with service users (those seeking or required to undergo professional assistance programs for their drug use) and service providers (those who facilitate such programs), it appears that current interventions serve to emphasise deficits and reinforce marginalisation of those who choose to use illegal drugs. This article provides a critique of the underlying perceptions of current intervention methods, and discusses the role an empowerment or strengths perspective might play.

 'I'd hate to advocate drugs, alcohol or insanity to anyone ... But
 it works for me.'

 Hunter S Thompson

The use of illegal substances and those who choose to use them are discussed and debated in almost every forum, from dinner tables to Parliament House. The subject is controversial and, as a result, interventions designed to assist those who are engaged in illicit drug taking reflect these value judgements and personal convictions. Through my social work practice with individuals coerced by the justice system into 'treatment' for their substance use, I began to recognise the need for a different understanding of illicit substance use and a new approach for working with individuals who use. The privilege of working with people and their personal challenges provides an insight that is not easily matched in the academic world; it provides us with an opportunity to question commonly held beliefs and, in turn, assists in considering alternative ways of looking at the same issue.

Working with those who are either imprisoned, or in the community and subject to orders of the court, allows not only for a different view of everyday life, but a realisation that many 'rehabilitative' approaches are developed in what could be described as an alternate reality. In the case of illicit substance use, policy and procedures are developed from the perspective that all illicit substances are harmful and problematic for those who engage in their use. Interventions developed from this perspective seek to cure the individual. For some, this approach is useful, but for those who do not consider their substance use problematic in the first place, the need to be cured is almost nonsensical. While working with those classed as offenders, it became apparent to me that the issue of illicit substance use was far more complex than drug users simply altering their consciousness, making enforced change a presumptuous suggestion. Whilst the argument for recognising the complex nature of illicit substance use by this population is not original, advocating that the areas targeted for change be instead strengthened as useful personal resources might be.

Hearing a myriad of stories from this population, I began to sense that traditional methods of illicit substance use intervention were lacking something, despite the good intentions of practitioners. Through further investigation into the research that informs these approaches, I discovered that no one had actually consulted at any length with the individuals such treatments were designed to 'fix'. The use of illicit substances is frequently examined through a negative lens, with an emphasis on identifying the problems associated with such use and, more significantly, the deficits of those who engage in illicit drug use. (1) It is not difficult then to understand the possible reluctance of individuals to engage in the 'treatment' intended for them.

PREVAILING TREATMENT MODELS

From the temperance movement with its message of prohibition and abstinence to the contemporary pragmatics of harm minimisation, moral overtones are conspicuous in many approaches to illicit substance use and illicit substance use intervention. A brief precis of past and present approaches to substance use intervention reveals thinly veiled value judgements that may compound the experience of marginalisation by a drug user.

Moral models depict the illicit substance user as guilty of committing sin against a higher law, in most cases represented by God. It is this view that underpins Alcoholics Anonymous and the more recent Narcotics Anonymous. This approach is often referred to as the Twelve-step program or the Minnesota model. (2) The basic tenet of this approach is that the individual needs daily vigilance to maintain their abstinence and avoid a return to problematic use. This approach has no place for controlled use, and ultimately requires that individuals accept their 'inability' to control this aspect of their lives.

The disease or biomedical model has some themes reminiscent of the moral model in that individual failing is implicated in illicit substance use. Through various twin and family studies it has been concluded that problematic illicit substance use is, in part, a result of genetic factors, meaning that certain individuals are predisposed to this problematic use. (3) Further research in the biomedical field sought to pathologise illicit substance use as a disease, or the result of innate personality defects, and therefore requiring medical treatment. (4) The goals of total abstinence and 'cure' echo the moral model's injunction to repent and relinquish self-power to a higher authority. In this case, however, the individual should defer to doctors and medical treatment rather than to God. This approach reinforces the underlying presumption that substance use can only be controlled by an exterior intervention, and that the individual has little or no control over their use or the issues associated with it. (5)

This biomedical model is an example of an approach that focuses on individual deficits and not on strengths. Substance users are considered deficient and their sense of autonomy is therefore muted. The presupposition that the use of illicit substances is harmful and has no benefits whatsoever for an individual is inherent in this approach and desisting is regarded as the only solution. The language used in relation to intervention--'treatment', 'assessment', 'diagnosis'--reinforces this view. The use of medical settings such as clinics and rehabilitation facilities further implies that the individual requires the assistance of 'experts' and sterile environments removed from the community.

A deviance/psychosocial-oriented approach to substance use incorporates factors that are both external and internal to the individual. It identifies stressors in an individual's life that may contribute to the initial use and then subsequent return to illegal drug taking. This model informs interventions like Relapse Prevention, for example, a strategy that accepts that relapse is a normal part of the process of change in any substance use behaviour. (6) Despite the fact that this approach avoids directly blaming the substance user, it still assumes weakness and an inability to cope. Likewise, Cognitive Behavioural Therapy, currently the most common approach to intervention with coerced individuals, is fundamentally about skills development. This approach involves teaching new skills and strategies to individuals for whom decision-making has been counter-productive. Motivational Interviewing (7) is a further technique that draws on this perspective. It is based on the premise that in order for an individual to consider changing their use of a substance they must experience cognitive dissonance: the personal realisation that the costs of their use (financial difficulties, relationship breakdown and health issues) outweigh the benefits (feeling good, relaxation or increased confidence). Whilst the approach appears to work remarkably well with middle-class problematic alcohol users who do have resources they would prefer not to lose, for those who are imprisoned and with limited access to a variety of financial and emotional resources, the costs do not necessarily outweigh the benefits.

Ultimately, these approaches reinforce the same perceptions of the substance user as weak, deficient and with impaired decision-making abilities. Ultimately the rehabilitative process seeks to replace or remedy familiar patterns with 'better' ones through accepting personal weaknesses or altering thought processes and developing coping strategies. Whilst these new tools make sense and can be learned, even by those legally coerced to learn them, these approaches give little recognition to existing strengths or positives in the individual's emotional and behavioural strategies, instead regarding them as inherently faulty. It is very much a case of 'out with the old and in with the better', according to the outside 'expert'. These approaches are also limited by how well the individual can sustain these largely imposed new behaviours when back among the pressures of everyday life in the community.

EMPOWERMENT & ILLICIT SUBSTANCE USE

A very different picture begins to emerge if instead of imposing our values and beliefs onto the individual we are seeking to help we attempt to understand the experience of illicit substances from their point of view. The argument that those convicted of crime are somehow undeserving of this consideration becomes redundant when we consider that at some point they will be released from the prison facility or would have served the required period of time under supervision in the community. My attempt to view illicit substance use as anything other than dysfunctional is admittedly ambitious; the implications, however, could be far-reaching. I am seeking to explore illicit substance use from an empowerment perspective and to investigate the possibility that there may be a relationship between the experience of using illicit substances and a sense of empowerment. Is it possible to think of illicit substance use as a means through which an individual may attempt to empower him/herself? Can illicit substance use be considered a means through which an individual forges a connectedness with others, and a sense of purpose and identity? How would this approach change the way we work with illicit substance users?

'Empowerment' and 'empowering practice' in social work denotes an approach that seeks to give or share the power inherent in a 'helping' relationship with the service user. The term 'service user', now commonly employed among social work professionals, is an attempt to redress the negative connotations of labels such as 'patient' or 'addict' that disempower individuals. In this context, 'service user' refers to any individual who seeks or is the recipient of social work services, both voluntary and involuntary.

In the context of this research, empowerment is viewed as a process through which an increased sense of power is experienced. (8) Intrinsic to a social work approach is the linking of theoretical perspectives with practice and practical application, and historically the same is true of empowerment. Traditionally empowerment has been explored in relation to issues of race and gender. Solomon, for example, highlights the fact that when working with marginalised groups, social work practice has in the past reinforced the oppressive structures they sought to challenge. (9)

Despite the radical aims of the empowerment approach to equalise the power dynamic between social workers and their clients, critics have raised questions about how fully this can be achieved, given that the worker remains an agent of social control and ultimately a representative of the system that of itself disempowers. (10) As Marlatt and Gordon write: 'The professional caseworker is seen as contributing to social control by subtly holding clients in powerless positions and reinforcing the identities ascribed to them by the dominant order.' (11) This is a valid critique, and suggests the need to re-examine an empowerment approach in this context, and perhaps the way it is applied across social work practice. However, an empowerment approach still has much to offer. If applied rigorously, an empowerment approach recognises the political implications of personal problems, and the need to view individual problems in their social context. (12) It recognises that we are not all from a level playing field and that there are distinct differences between those who have access to resources and those who do not. Critical appraisals of an empowerment approach in more recent times have actually served to enhance its effectiveness.

Empowerment has become a legitimate theoretical approach to working with a myriad of marginalised groups, and in the last thirty years this has gone beyond issues of race, gender and poverty to include those disempowered as a result of sexual orientation, mental health, HIV status and disabilities. (13) Issues faced by people who identify with these groups are often viewed through a particularly narrow lens, frequently with medical or moral overtones. As with illicit substance use intervention, medicalised language and discourse immediately create a power imbalance, where the 'patient' or 'subject' of the service submits to prescribed 'treatment' by the professional. The implied meaning is that the service user is in fact incapable of making decisions about their situation, even to the extent of making decisions about what they put into their own body. The parallels between these marginalised groups and illicit substance users are marked; the empowerment approach developed for these groups can therefore be usefully extended to illicit substance use.

Societal perceptions and prejudices relating to the use of illicit substances marginalise users and often those involved with intervention. Previous research indicates that societal prejudices are so insidious that even where service providers attempt to implement an empowerment approach, the effect is often quite the opposite, as studies by Cowger and Curtis and Harrison suggest. (14) These results in particular illuminate the impact of societal views on both service providers and service users as a result of their involvement with illicit substance use issues. The highly subjective and moralistic way in which this issue is approached has inevitably translated into a discourse that can only serve to alienate. An alternative perspective that attempts to highlight the strengths in the individual and to move away from blame and subjugation offers a more optimistic vision for the future.

LEGAL COERCION INTO TREATMENT

As a result of their offender status, those legally coerced to address their illicit substance use following a conviction have few choices available to them. There is seemingly little in the way of research that considers those legally coerced into 'treatment' to be experiencing empowerment or lack thereof, which makes the research presented here unique. If empowerment is about process--'the mechanism by which people, organisations and communities gain mastery over their lives' (15)--then a strengths perspective of illicit substance use may recognise 'mastery' in the regular procurement of the substance and the link with identity and subculture associated with illicit substance use. My research seeks to document the thoughts and experiences of those legally coerced into substance use 'treatment', and this is consistent with the aims of empowerment theory. Proceeding with the underlying belief that those who are the focus of any intervention--the service users--are an invaluable source of wisdom may well contribute to a sense of empowerment on their part and assist in broadening this vision to include theirs.

Preliminary findings from in-depth interviews conducted with participants from prisons in Western Australia and Victoria indicate that, for many, substance use is associated with empowering social and personal experiences such as feeling respected, confident, connected to a group or 'part of something'. In the words of one service user:

 the respect that I was getting because of my drug use, because I
 was a leader I guess of the guys ... and the opportunities you used
 to get because of it ... [it] used to bring in money and you used
 to be able to have a car, girls and friends and go places and do
 things that other kids my age wouldn't have a hope in hell of
 getting.

While the users interviewed recognise the negative consequences associated with illicit substance use, they also consistently relate stories of illicit substance use being the means through which an identity has been forged, as this quote indicates. Service providers similarly acknowledge this aspect of substance use:

 I think it's incredibly hard to make the changes, especially for
 the clients that we work with in the justice system. Often they
 don't have a licence, they don't have a lot of supports, very
 limited education and to move that person out of where they are,
 which is actually functional for them to some extent, there is a
 lot of positives that they get out of that lifestyle--they have
 ways of getting regular income, there might be costs associated
 with that such as going to jail but they have peers around them,
 their social group. Like we have been saying, most people they
 know also use, so that (change) means no friends, no job, no
 education, no money.

The examples presented here show that both service users and service providers recognise that the use of illicit substances assists in developing certain skills and attaining goals that are not far removed from those promoted in general society. If we acknowledge that substance use can be empowering and serve a positive function in some user's lives, then we can explore alternative approaches to illicit substance use intervention. The emphasis here is on approach; there is little sense in re-inventing well-established clinical practice. Instead, my proposal is to enhance current intervention through building on the strengths that substance users already display. Current approaches appear to create a significant amount of resentment in the service user that, one might speculate, impacts on intervention outcomes. As one service user explains:

 You are never going to make him think like a straight person, he is
 not a straight person, they are not straight people, they are what
 they are, and that is the biggest problem with every program I have
 been in, they have tried to do that, I am yet to see one that
 accepts us for what we are, and allows us to think and find some
 other ways to try and change the cycle and the only way you can
 really change the cycle is by allowing the cycle to exist to start
 with.'

A VISION SPLENDID

What would it mean to consider illicit substance use as more than a form of escapism or a behaviour that requires stern regulation if not prohibition? Is it possible that for some, illicit substance use provides identity and status for those without ready access to other roles in society? Using illicit substances can provide connectedness with others and the sense of belonging that everyone craves. Work colleagues are people that we have at least one thing in common with and through whom we define our own role in a particular setting. The same could be said for the individuals with whom illicit substance users spend their time; both are equally valid in contributing to a sense of self. Where illicit substance use has become the norm within a family setting, change would mean possible exclusion from family gatherings and support. Illicit substance use is not as widely acknowledged as alcohol, for example, in being integral to social events and relationships. Some may argue that normalising certain behaviours results in the active promotion of such behaviour; however, it may also make change more of a socially inclusive process.

[FIGURE 2 OMITTED]

The implications of approaching illicit substance use from an empowerment or strengths perspective can be seen as twofold. The first fundamentally relates to how we perceive those who choose to use illicit substances. It does not suggest that acknowledging the negative consequences of problematic use is not equally important. It is suggesting that those involved in illicit substance use to the point where they are coming into contact with correctional services are often striving for the same ends as any market-savvy entrepreneur. For substance users there is the promise of money, respect and power--goals that are promoted to us every day by the media. The research discussed here seeks firstly to establish that there is some relationship between illicit substance use and empowerment for this population, and preliminary findings appear to support this contention.

Whilst these suggestions may be abhorrent for some, my point is that without a better understanding of what illicit substance use means for particular individuals, interventions that seek to alter this behaviour are difficult to sustain when the program is completed. It is recognised and acknowledged that illicit substance use also carries a degree of risk. However, this is relative to an individual's situation at any one time. Risks are presented to people in all avenues of life, whether in relationships or work and, as in these examples, choices are made that are not necessarily based on a full consideration of the consequences, or are made in spite of them. If we could conceive of illicit substance use as the means through which an individual may attempt to empower his/ herself, then any proposed intervention would focus on the strengths rather than the deficits within that individual. If we see that their choice to engage in illicit drug taking behaviour is a result of limited alternatives, we can circumvent moral judgement making.

The second implication is the need for intervention practice to explore with an individual the meaning of their drug use and the skills and strategies they have already developed in tackling daily issues. This approach would focus on building up the areas of strength and developing fledgling areas of pride and support, rather than prematurely condemning an area of so-called dysfunction. It would also seek a better intervention match from the outset, by taking the time to ascertain which learning environments may be best for an individual and their needs at a particular time. In very basic terms, it means viewing the individual as a human being with resources, potential and finely tuned survival skills.

The research process I have demonstrated here, in documenting and therefore validating the perceptions of individuals about their own substance use, aims to give them greater empowerment and respect within both the immediate circle of intervention service providers and users, and the wider community. Through my research, I also hope to give them a voice in the academic community. In soliciting and documenting the experiences of those who live and work with this issue, my research has uncovered several themes that suggest a different way of approaching illicit substance use. It has also shown how strong the discourse of previous intervention approaches--involving moral, medical or emotional deficit--has been. The language and conceptual tropes we use can be a powerful indicator of a society's perceptions of illicit substance use, and have in many cases served to reinforce disempowering structures. Through simply offering an alternative perspective for discussion by those who could be described as major stakeholders, I hope to make a significant first step towards challenging current practice and envisioning a different future. My preliminary findings confirm that intervention practitioners make a significant contribution to the field and, more importantly, show creativity in the ways they implement often-restrictive programs and handle the inflexibility of large conservative organisations.

My research proceeds from the understanding that new insights into the use of illicit substances by those legally coerced into intervention will contribute to an improved way of understanding this phenomenon. New understanding will in turn inform future directions in program development. The ultimate goal would be to have an approach that may better acknowledge the significance of illicit substance use in the lives of some individuals and, respectively, the magnitude of the request for them to change. It is not the intention here to discredit the current methods of intervention in the field but rather to suggest that they may be further enhanced. My vision is that illicit substance use intervention is tackled with fresh enthusiasm and an outlook that harnesses the strengths of both the individual and the community in a more creative way.

ENDNOTES

(1) For examples, see John Strang & Michael Farrell, 'Illicit Drug Use: Clinical Features and Treatment', in Jonathon Chick & Roch Cantwell (eds), Seminars in Alcohol and Drug Use, Royal College of Psychiatrists, London, 1994, 33-52; Joseph Westerneyer, 'Historical and Social Context of Psychoactive Substance Disorders', in RJ Frances & SI Miller (eds), Clinical Textbook of Addictive Disorders, Guildford Press, New York, 1998; NE Zinberg, Drug, Set and Setting: The Basis for Controlled Intoxicant Use, Yale University Press, New Haven, 1984; Jon Morgaenstern, Kimberley Blanchard, Thomas Morgan, Erich Labouvie & Jumi Hayaki, 'Testing the Effectiveness of Cognitive-Behavioural Treatment for Substance Abuse in a Community Setting: Within Treatment and Post-treatment Findings', Journal of Consulting and Clinical Psychology, vol.69, no.6, 2001, 1007-17.

(2) Helen Keane, What's Wrong with Addiction?, Melbourne University Press, Melbourne, 2002.

(3) Chick & Cantwell.

(4) Philip Mendes & James Rowe (eds), Harm Minimisation: Zero Tolerance and Beyond--The Politics of Illicit Drugs in Australia, Pearson Education Australia, Sydney, 2004; Caroline J Acker, Creating the American Junkie: Addiction Research in the Classical Era of Narcotic Control, Johns Hopkins University Press, Baltimore, 2002.

(5) See Keane.

(6) Gordon Marlatt & Judith R Gordon (eds), Relapse Prevention, Guildford Press, New York, 1985.

(7) William R Miller & Stephen Rollnick, Motivational Interviewing: Preparing People to Change Addictive Behaviour, Guildford Press, New York, 1991.

(8) For examples of this approach, see Margot Breton, 'On the Meaning of Empowerment and Empowerment-Oriented Social Work Practice', Social Work With Groups, vol. 17, no. 3, 23-37; Judith Lee, The Empowerment Approach to Social Work Practice, Columbia University Press, New York, 2001; Malcolm Payne, 'Empowerment and Advocacy', in Modern Social Work Theory: A Critical Introduction, Macmillan Education Ltd., London, 1991; Elaine Pinderhughes, Empowerment for Our Clients and for Ourselves, Social Casework, 1983, 331-338; Stuart Rees, Achieving Power: Practice and Policy in Social Welfare, Allen & Unwin, Sydney, 1991.

(9) Barbara Bryant Solomon, Black Empowerment: Social Work in Oppressed Communities, Columbia University Press, New York, 1976.

(10) Tim Gilley, 'Explorations in empowerment: How to improve empowering welfare practice', in Social Work Department, University of Melbourne, Melbourne, 1997, 213; Anne Wilson and Peter Beresford, 'Anti-oppressive practice: Emancipation or appropriation?', British Journal of Social Work, vol. 30, 2000, 553-573; John Solas, 'The limits of empowerment in human service work', Australian Journal of Social Issues, vol. 31, no. 2, 1996, 147-56; James Ife, Human Rights and Social Work, Cambridge University Press, Cambridge, 2001.

(11) Janis Fook, Radical Casework: A Theory of Practice, Allen & Unwin, New South Wales, 1993.

(12) Fook.

(13) Robert Adams, Social Work and Empowerment, Macmillan Press, London, 1996.

(14) Janette Curtis & Lindsey Harrison, 'Beneath the Surface: Collaboration in Alcohol and Other Drug Treatment. An Analysis Using Foucault's Three Modes of Objectification', Journal of Advanced Nursing, vol. 34, no. 6, 737-744; and Charles D Cowger, 'Assessing Client Strengths: Clinical Assessment for Client Empowerment', Social Work, vol. 39, no. 3, 1994, 262-268.

(15) Julian Rappaport, Carolyn Swift & Robert Hess, Studies in Empowerment: Steps Toward Understanding and Action, Haworth Press, New York, 1984.