‘Incompatible Knots’ in Harm Reduction

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Since the introduction of the harm reduction paradigm in the 1980s, it has almost universally been presented as the ‘self-evidently correct’ and ‘rational’ approach to the problems associated with drug use (Erickson 1995; Roe 2005; Single 1995; Weatherburn 2009). It frequently pits itself against recovery-orientated paradigms, characterizing them as punitive, narrow in perspective and ‘rooted in punitive law enforcement models and in medical and religious paternalism’ (Newcombe 1992: 1), or as undermining the freedom, dignity or positive self-image of individuals with substance use disorders (Ezard 2001; Zajdow 2005). Instead, harm reduction is often presented as a humane, value-neutral, pragmatic and scientific alternative, and is, thus, often accepted uncritically as an obvious and unqualified good (Marlatt 1998; Souleymanov & Allman 2016).

Yet, harm reduction proponents are frequently ill-informed of the epistemological and ontological assumptions that underlie their theories and interventions. When some of these assumptions are accepted as ‘self-evident’, harm reduction can become beleaguered with internal inconsistencies and uncertainties in its core goals (Keane 2003; Mugford 1993; Weatherburn 2009). An internally contradictory position within harm reduction theory and practice can create a ‘double bind’, that results in what existential psychiatrist Ronald D Laing (1960) refers to as an ‘incompatible knot’. Psychologically, a ‘double bind’ (see Bateson 1972) gives rise to the experience of cognitive dissonance, where the individual often relies on misperception, rejection or refutation of the contradiction to restore psychological consonance (Harmon-Jones 2002).

In this essay, informed by critical hermeneutics (Gadamer 1975/1960; Ricoeur 1981), I provide a brief philosophical analysis of some of the foundational suppositions that often underlie harm reduction theories and interventions. I deliberately take on the ‘strong’ versions of these suppositions in order to reveal what I consider to be at stake. I will limit my focus to three theoretical orientations (or ‘-isms’), often advanced by harm reduction proponents, which contribute to internal inconsistencies within harm reduction theory and interventions. These are relativism, which leads to conflation of drug use and addiction as concepts and to conflation of ‘drugs’ in general; collectivism, which prioritizes the common good over that of the individual; and determinism, which represents people with addiction as victims with limited agency. I conclude by proposing the value of an integrative and metaparadigmatic heuristic that could possibly assist our conceptualization of addiction and ameliorate the conceptual challenges and internal inconsistencies present in harm reduction theory and practice. The value of a comprehensive and integrative framework is that it provides a more accurate conceptualization of drug use, addiction and its harm; this ‘right view’ lends itself to ‘right action’.

I also present the argument that addiction, as a concept, has social and human value as well as empirical merit and that harm reduction strategies should be an important link in the continuum of recovery-oriented systems of care. But, as I will show, there are problems with promoting harm reduction uniformly as an alternative, ‘better’ or ‘fix all’ intervention.

It is common for harm reduction proponents to conflate the behavior of drug use and the condition of addiction (Davies 1997; Peralta & Jauk 2011) and to minimize the distinctions between medications commonly prescribed by the healthcare system and those (such as opioids) that are diverted into non-medical economies for their intoxicant and dependency-producing properties.For the purposes of this essay I will use the term ‘drug use’ to make a distinction (and avoid conflation) between ‘substance use’ and ‘substance use disorders’. The term ‘addiction’ normally refers to a broad category of behavior; this chapter will limit its discussion to substance use disorders as defined in the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (APA 2013). I will make a distinction between ‘categorical conflation’ and ‘continuum conflation’. Categorical conflation (which will be my focus here) can be considered as denying any categorical difference between drug use and addiction, whereas continuum conflation acknowledges some differences but assigns enough similarity to place it on an ontological continuum. I argue that both these types of conflation of drug use and addiction are serious conceptual errors that lead to deleterious consequences for the design and sustainability of harm reduction policy.

Comparing drug use to addiction is like comparing apples and oranges. Drug use and addiction are distinct phenomena and harm reduction interventions for drug use and addiction should be fundamentally different. Makings claims whether drug use is good or bad is a normative statement and stating whether someone is an addict or not (and how to treat addiction) is a descriptive or positive statement. According to ‘Hume’s law’, we cannot derive normative statements (how we ought to act) from descriptive statements (what is) because there is a fundamental difference between how we should act morally and how the world factually is (Hume 2003/1739). Addiction is not morally good or bad; it just is. It is a scientific concept; whether it is present or not is a descriptive/positive statement. Normative conflation of drug use and addiction returns us to a moral model of addiction (Pickard et al. 2015). This model applies a normative orientation to both drug use and addiction and concludes that both are moral failings and should be judged and treated accordingly (Mugford & Cohen 1988). ‘The parallel would be with theorizing alcohol usage in general on the basis of what is known about institutionalized alcoholics” (Mugford & O’Malley 1991: 27).

One of the primary reasons that many harm reduction proponents conflate drug use and addiction is because they tend to have a have a relativist view of drug use and addiction, influenced by strong social constructionist perspectives (Davies 1997; Dingelstad et al. 1996). ‘Strong’ social constructionism as a philosophical approach tends to suggest that “the natural world has a small or non-existent role in the construction of scientific knowledge” (Collins 1981: 3). Applied here, it proposes that addiction exists as a dominant and historically produced narrative, which would cease to exist if we thought, wrote and spoke about it differently (Davies 1997). ‘Weak’ social constructionism proposes that many of the concepts and approaches to addiction are socially constructed but concedes that there is an underlying reality to some of them; it is perhaps best defined as epistemological pluralism. Proponents of strong social constructionism call addiction a ‘myth’, a phenomenon that does not really ‘exist’ outside our collective perception, and even that ‘drugs’ are social constructions (Davies 1997; Hammersley & Reid 2002). Jacques Derrida, for example, concluded that “the concept of drugs is a non-scientific concept, that it is instituted on the basis of moral or political evaluations: it carries in itself norm or prohibition, and allows no possibility of description or certification” (1995: 229). While the concept of ‘drug’ carries ambiguities and social meanings that impact policy, the differing chemical nature of psychoactive substances and their potential bioactive consequences on a body and psyche must be recognized and respected.

Although there is a cornucopia of perspectives on addiction, which makes a unified understanding a challenging prospect, it is nonetheless erroneous to deny the ontological reality of addiction through adopting a position of epistemic relativism (Du Plessis 2018). There are certainly ways to maintain epistemological plurality while not holding to a strictly realistic metaphysics. Adopting a form of critical or pragmatic realism (Bhaskar 1997; Harre & Moghaddam 2012) conceptualizes addiction without submitting to judgemental relativism (giving equal voice or weight to multiple theories or interpretations). In the trenches of the therapist working with addicted populations, and parents who have addicted children, a radically relativist perspective of addiction has little value and purchase, and can even be harmful.

Harm reduction proponents often profess that their approach has “roots in humanitarianism and libertarianism” (Newcombe 1992: 1), which place primary emphasis on individual liberty and individualism. Yet there is also a tendency by many of them to adhere to social justice ideology (Friedman 1998; Pauly 2008), which inherently favors collectivist values and epistemology. Individualism is a cultural value that prioritizes the interests of the individual over the state or social groups, whereas collectivism prioritizes the interests of group or state over the individual (Schwartz 1990). For example, groups like the Harm Reduction Coalition identify as a ‘movement for social justice’ (Greig & Kershnar 2002: 365). Social justice can be defined as a position that aims for the eradication of all forms of social oppression and inequality and, frequently, for one form or other of economic redistribution (Feagin 2001). A harm reduction approach that is informed both by the collectivist values of a social justice orientation and the individualist values of libertarianism can become internally inconsistent.

Several detrimental consequences can result when harm reduction policies are geared towards collectivist instead of individualist aims. The influence of social justice activists has moved the aim of harm reduction away from helping the individual towards that of the ‘common good’. Mugford (1993) points to the self-contradictory nature of harm reduction’s adherence to its utilitarianism (informed by collectivist values, through which draconian anti-drug strategies have been defended) and its liberal values (based on humanistic and libertarian perspectives, the protection of civil liberties and human rights). Miller’s (2001) view is that the primary impulse of many harm reduction programs has not been out of concern for the individual drug user, but rather for the benefit or protection of the general public and the reduction of healthcare costs. Indeed, for some harm reduction organizations and activist groups, syringe exchange is merely a means to an end, a political activity and not a value-neutral healthcare intervention, even though it is often proclaimed by harm reduction supporters that one of the major strengths of harm reduction is its value-neutral standpoint on drug use and drug users (Newcombe 1992; Riley et al. 1999). Therefore, the incorporation of social justice ideology (or any political ideology) into the harm reduction paradigm contradicts the professed value-free neutrality of harm reduction. In extreme cases, harm reduction threatens to become a ‘holy cause’, a kind of mirror to the moral righteousness behind the politics driving the ‘war against drugs’. As Eric Hoffer, author of The True Believer, reminds us:

“The burning conviction that we have a holy duty toward others is often a way of attaching our drowning selves to a passing raft. What looks like giving a hand is often a holding on for dear life. Take away our holy duties and you leave our lives puny and meaningless. There is no doubt that in exchanging a self-centred for a selfless life we gain enormously in self-esteem. The vanity of the selfless, even those who practice utmost humility, is boundless”. (1951: 23).

Like Hoffer (1951), Karl Popper noted we should be wary of the professed ‘selflessness’ of proponents of collectivist ideologies like social justice: “Collectivism is not opposed to egoism, nor is it identical with altruism or unselfishness. A collectivist can be a group-egoist. He can selfishly defend the interest of his own group, in contradistinction to all other groups. Collective egoism or group egoism (e.g. national egoism or class egoism) is a very common thing. That such a thing exists shows clearly enough that collectivism as such is not opposed to selfishness” (Popper et al. 2008: 65).

This ‘collectivist egoism’ is very prominent among social justice-oriented harm reduction proponents. It often manifests in dogmatism, and ‘insulates itself against criticism, regards non-believers as a threat, and refuses to examine evidence coming from outside the closed circle of gratifying ideas’ (Rodger Scruton, personal communication, 5 August 2018). The bias of an overly collectivist approach to addiction is also exemplified in research, where nearly all attention has focused on indicators of change that are observable and socially desirable, such as abstaining from drugs, avoiding criminal activity and obtaining gainful employment. It frequently neglects other, more functional, indicators, such as quality of life and satisfaction with treatment, that bear more importance to drug users themselves (Fischer et al. 2001). And, perhaps most crucially, rarely have studies explored the congruence of these outcomes with the perspectives of drug users (Fischer et al. 2001). The currently available instruments, such as the generic Nottingham Health Profile, were developed for and by professionals without input from drug users or their families and caregivers (Fischer et al. 2001). Their viewpoints are notably missing from the literature. According to Saleebey (1996: 301) oppressed or marginalized populations typically have ‘[their] stories buried under the forces of ignorance and stereotype’. In the context of this essay, I would argue that drug users often have ‘their stories buried under the forces of ignorance and stereotype’ of collectivist thinking.

The largely uncritical acceptance of a social justice ideology by harm reduction proponents and the influence of social justice activists who choose harm reduction as a platform to promote their ideological aims will continue to have a deleterious effect. Social justice activism is a political project; harm reduction approaches should not be driven by collectivist political agendas, and we do not need more ‘true believers’ (see Strang 1993). Instead, we require the perspectives of people who identify as addicts, empirical research, clinical experience, concern for drug users as individuals and pragmatic health aims. Strang notes that “the true champion of harm reduction is neither for nor against increased civil rights for users … neither for nor against the legalization or decriminalization of drug use … except insofar as one or other of these choices influences the nature and extent of harms consequent upon the drug use” (1993: 3–4).

Due to its libertarian foundations, harm reduction proponents purport to acknowledge the existence and value of human agency. However, due to the influence of social justice ideology, many also tend to ascribe to a radically deterministic view of addiction, based on the premise that social pathologies are addiction’s ‘root cause’. The pitfall here is when social factors, which of course contribute to patterns of drug use, are considered determinate. Ironically, ‘overgeneralization from the [social] deficit model is the fundamental political and theoretical error which underlies prohibitionist strategies’ (Mugford & O’Malley 1991: 28).

Social justice proponents often conceptualize society with over-simplified dichotomies of power and status, such as ‘oppressor/privileged’ and ‘oppressed/ non-privileged’, and present a socially deterministic framework, where drug use has been identified as a symptom of gender oppression (Travis 2009), as a reaction to internalized homophobia (Bobbe 2002) and so forth (Ettorre 2007). It introduces a new moralism by suggesting that problematic drug use might be a ‘rational’ response to (in some cases generalized) social victimhood. Robert Peralta and Daniela Jauk (2011: 890), for example, postulate that various forms of “social inequality … are often sources of substance use and abuse and their noxious corollaries.” Apart from presenting a radically deterministic position, such statements once again conflate drug use and addiction. Social justice proponents often epistemologically prioritize ‘social inequality’, in which the individual drug user is the hapless victim of an unfair, deficient or exploitative world. But, as Mugford and O’Malley state: “such a [social] deficit model must be considered against the fact that the fastest growth in drug use arose [in many parts of the world] in the affluent 60s and 70s … It was the privileged in search of pleasure, not the underprivileged in search of escape who provided the impetus for the development of large-scale cocaine trade” (1991: 24).

Social inequality and pathology “[are] associated with certain kinds of psychotropic drug use in the present period, but it is neither a necessary nor sufficient condition for such use” (Mugford & O’Malley 1991: 24). The truth is that addiction and drug use are ‘great equalizers’ and cut across all boundaries and identities of class, gender, sexuality, race, culture and religion (Amodeo & Jones 1997).

Bruce Alexander (2008) presents a ‘social deficiency model’ in his dislocation theory of addiction, where he posits the globalization of free-market capitalism as the primary etiological factor of addiction on a population level. This is a highly contestable position. While he pushes hard against the physiologically reductionist ‘brain disease model’ of addiction (represented, for example, by Volkow et al. 2002), he proves himself equally reductionistic, reducing the numerous etiological factors of addiction to primarily socioeconomic factors. Alexander is not alone among harm reduction proponents in his critique of biological determinism of the ‘brain disease’ school (Leshner 1997). Yet, ironically, harm reduction advocacy “has also extended the “disease” model of addiction, labelling drug users as permanently disabled by their dependence on drugs” (Roe 2005: 247). While building on the early twentieth-century trope of ‘enslavement’, a deterministic formulation of harm reduction does not provide an emancipatory option for addicts. Instead, it disempowers them and “can be seen as a move from a problematic “curative” model, through prohibition and treatment, to an equally problematic “palliative” model” (Roe 2005: 248).

In the initial formalization of harm reduction, it was conceptualized as a needed partner to treatment and prevention. But, due to the influence of activists and ‘true believers’, it has metamorphosed into a worldview geared to legalization and ‘normalization’ of drug use (Mangham 2008). Nobody would deny that socioeconomic factors influence an individual’s behavior. But when we adopt a deterministic view of human existence, we risk conceptualizing individuals as being without agency or without the resilience to overcome obstacles, and thus doing injustice to human nature and the individuals we purport to help.

A socially deterministic view of addiction implies that individuals have little or no free will, are psychologically homogenous, and are at the mercy of their environment. Taken to its logical conclusion, a socially deterministic view would mean that the entire sociopolitical structure of our world must be changed to effect change on an individual level. This is a dangerous point of view, as clearly articulated by Popper in his book The Poverty of Historicism (2002). is no doubt that drug users and addicts are often viewed as outsiders and are historically and currently marginalized to varying degrees (see various chapters in this edited volume). But it is misguided to assume this is primarily due to ‘oppressive’ forces inherent in society, as a social justice view would suggest. One could as easily argue that for the addict their ‘marginalization’ is self-chosen and ‘embraced’ and, as long as “society is judging his behavior as an attack on civic unity, he will always remain homo oeconomicus while playing out his societal role as the negative hero” (Zoja 1989: 15).

Most crucially, by adopting a socially determined view, the consequent solutions will be equally socially determined and at odds with many of our basic human rights. A socially deterministic view of recovery or harm reduction has obvious appeal to governments and pharmaceutical corporations. Personal responsibility and agency have no market value, but victims can be sold many ‘external solutions’ to their ‘problem’, whether through social engineering or pharmaceutical interventions. I find it ironic that although many harm reduction proponents are often critical of ‘Big Pharma’ and the ‘medical-industrial complex’, most of their solutions are pharmacological and medical, such as opioid substitution therapy and needle exchange programs for intravenous drug users to reduce the transmission risk of HIV and hepatitis B and C (Single 1995). Harm reduction should not be understood as a paradigm that provides a palliative band-aid for a group of helpless victims at the mercy of their environment, but rather as a choice, among many, for drug users and addicts, as individuals with agency.

Many harm reduction commentators have argued that the “clarification of its defining characteristics and principles was crucial to its successful incorporation into policy and research” (Keane 2003: 227). This essay presented the argument that harm reductionists must look more carefully at the suppositions that underpin their advocacy, and that an uncritical acceptance of the ‘defining characteristics and principles’ of harm reduction can lead to internal inconsistencies, and consequently the harm reduction movement will continue to be beset by conceptual confusion, lack of efficacy and ideological conflicts. It was pointed out that the ‘incompatible knots’ often found in harm reduction theory and interventions can be ameliorated by a critical review of its foundational premises.

Moreover, harm reduction proponents should not present their approach in opposition to recovery-orientated approaches, especially since they are embraced by many, and self-help groups like 12-step programs are easily accessible and freely available across all socioeconomic axes. Many harm reduction proponents are critical of 12-step programs, despite the clear benefits that many have found and its ubiquitous and ‘grassroots’ approach that makes it available regardless of socioeconomic background. Unfortunately, it is often the case that those ‘who write disparagingly of the organization do so without the benefit of attending AA meetings or familiarizing themselves with its working on more than a passing, superficial, or purely analytical level. They fail to understand the subtleties of the AA program and often erroneously attribute qualities and characteristics to the organization that are one-dimensional and misleading’ (Flores 1997: 249).The conceptual schism between harm reduction and recovery-orientated approaches, where these approaches are often discussed in either/ or terms within the context of strategic drug policy (Ezard 2001; Zajdow 2005), is a false dilemma. Instead, harm reduction should be an important link in the continuum of recovery-oriented systems of care. But when harm reduction is promoted as a ‘better’ or ‘stand-alone’ approach, it can do more harm than good.

In conclusion, I propose that an integrative metaparadigmatic heuristic, through the application of a critical or pragmatic realism (Bhaskar 1997; Harre & Moghaddam 2012) and integral pluralism (Wilber 1995), could help to address the conceptual challenges by untangling some of the ‘incompatible knots’ in harm reduction theory and practice. In short, this metaparadigmatic heuristic points out that various explanatory views (models and theories) ‘co-arise’ depending on methodology (methodological pluralism), which ‘enacts’ a particular reality of drug use, addiction and its harm (ontological pluralism and complexity), while being mediated by the worldview of the subject applying the method (epistemological pluralism) (see Du Plessis 2012; 2014; 2018). The notion of enactment points out that reality is not to be discovered as a ‘pre-given’ truth, but rather that we co-create or ‘co-enact’ reality as we use various paradigms to explore it (Wilber 1995). This is not to be confused with a social constructionist position or epistemic relativism. From the above point of view some of the ‘incompatible knots’ in harm reduction theory are a result of epistemological and ontological reductionism.

The ‘-isms’ of relativism, collectivism and determinism each have an element of truth, but when given epistemological priority over other points of views, dissolve into a reductionist worldview. When we understand that the constructs of drug use, addiction and its harm can be enacted through various epistemological positions, we can appreciate a plurality of positions, without having to revert to relativism and deny its ontological reality. When the socioeconomic and cultural factors are given epistemological priority over individual factors, a deterministic and reductionist view of human nature results. Both perspectives (individual and collective) prioritize certain domains of our human ‘being-in-the-world’. Neither of these domains should be given epistemological and ontological priority, otherwise there is the risk of reductionism and creating a battleground of ‘-isms’. An existential perspective would point out that drug users are always situated ‘within-the-world’ (Boss 1983; Heidegger 1962/1927).

But being-in-the-world is not the same as being-a-victim-in-the-world. A socially deterministic view of harm reduction and recovery provides little emancipatory value and hope for the individual. In contrast, a non-deterministic and resiliency-orientated view of harm reduction and recovery (see, for example, integrated recovery meta-therapy, Du Plessis 2018) would propose that although we are in-the-world, we have the capacity to overcome the limitations of our ‘thrownness’. The latter position is congruent with the experience of millions of individuals in recovery from addiction.

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This earlier version of this essay was published as a book chapter in Du Plessis, G. P. (2019). Incompatible Knots in Harm Reduction: A Philosophical Analysis. In T. Waetjen (Ed.), Opioids in South Africa: Towards a Policy of Harm Reduction. Pretoria: Human Sciences Research Council Press.

Guy is a researcher at the I-System Institute for Transdisciplinary studies, Utah State University. He has published in the fields of psychology and philosophy.