Monday, March 21, 2011

Drug Policy: “Moralization” v. “Therapy”?

In a post at Concurring Opinions, “Drug Policy in the U.S.: A Turn Towards a Pragmatic, Therapeutic Approach?,” Danielle Citron writes:

“The Maryland General Assembly will soon consider House Bill 323 that eliminates mandatory minimum penalties for drug-related offenses, substituting them with maximum penalties. The bill also would expand eligibility for court-ordered drug treatment as an alternative to incarceration. This proposal may seen as part of a broader trend away from criminalization towards more pragmatic therapeutic approaches on as a strategy for drug abusers. But, as Richard Boldt’s thoughtful scholarship suggests (see here, here, and here), the concerns animating drug policy in the United States are complex and anchored in moral judgments that may be difficult to dislodge.

In Boldt’s view…a U.S. turn towards a more pragmatic, therapeutic approach, if it is to occur, must be ‘executed against the inertial force generated by policy commitments and social practices of more than seventy-five years in which the most dominant feature has been an intense moral disapproval of drugs.’ [….] The extreme moral disapproval that has been fixed in this country will likely continue to serve as an ‘anchoring-and-adjustment heuristic’ that ‘filters the complex array of information a pragmatist would want to consider in formulating sensible public policy in this area.’” [….]

What follows are my comments to the post:

There’s much to think about here that is not is amenable to what is tendentiously framed as a drug policy choice between “moralization” and criminalization v. “therapy” and pragmatism, if only because I think a true accounting will find some measure of truth possessed by both (so to speak) the moralists and the therapists. Being on the Left and liberal on most matters, I nonetheless find myself drawn to a perspective brought to this discussion by a thoughtful conservative like Theodore Dalrymple (the pen name of Anthony (A.M.) Daniels, a British writer and retired physician), a former prison doctor and psychiatrist, and author of Romancing Opiates: Pharmacological Lies and The Addiction Bureaucracy (New York: Encounter Books, 2006). Consider, for instance, the following from his book:

“The temptation to take opiates, and to continue to take them…arises from two main sources: first, man’s eternal existential anxieties, to which there is no wholly satisfactory solution, at least for those who are not unselfconsciously religious; and second, the particular predicament in which people find themselves. Modern societies have created, or at least resulted in, a substantial class of persons peculiarly susceptible to what De Quincy calls ‘the pleasures of opium.’”

Dalrymple proceeds to elaborate upon this second source:

“…[I]n most western societies, there is now a class in which tedium vitae is very common, almost normal. This is the class from which the great majority of heroin addicts now comes…. The young of this class are disaffected, and have good reason to be so. They are for the most part poor, though not of course in the absolute sense. On the contrary, they are healthier, better fed, dressed, and sheltered than the great majority of the world’s population, past and present, and dispose of appurtenances whose sophistication would have astonished our forefathers. But they are poor in the context of their own societies (which is what counts psychologically [such ‘relative poverty’ counts in other ways too, as Amartya Sen has recently argued]) and they are so badly educated (this time in the absolute sense) that any historical or geographical comparison, by means of which they might put their poverty in some kind of perspective, is completely beyond them.

They have no interests, intellectual or cultural. The consolations of religion are closed to them. As for their family lives, loosely so-called, it is usually of an utterly chaotic nature…. Their sexual relationships are a kaleidoscope of ephemeral couplings, often with abandoned offspring as a result, motivated by an immediate need for sexual release and often complicated by primitive egotistical possessiveness leading to violence and conflict. Their emotional life is intense but shallow, and their interactions with others governed by power rather than any kind of principle. Life is a matter of doing what you can get away with.

Their economic prospects are poor. They are unskilled in countries in which the demand for unskilled labour is limited. [....] Any work that they do will be repetitive and dull; and while a man might once have derived satisfaction from performing a menial task well, from leading a life of modest usefulness to others, this is not an age when such humility is very common. In large part, this is because people live to a quite unprecedented degree in the virtual world of so-called popular culture. From the very earliest age, their lives are saturated with images of celebrities, whose attainments are often modest but who have been whisked by good fortune into a world of immense and glamorous luxury. This comparison with their own surroundings, squalid if not poor in the literal sense, is not only stark but painful, and is experienced as an open wound into which salt is continually rubbed. It is also experienced as an injustice, for why should people with tastes and accomplishments not so very different from their own lead a life of fairy-tale abundance? The injustice of which they feel themselves to be the victim reduces any lingering inhibitions against causing harm to society, which means in practice individual members of society. Crime ceases to be crime, but is rather restitution or justified revenge. And the fact that the abundance they so desire is itself empty and leads to dissatisfaction and boredom entirely escapes them.

The end result is that, while profoundly dissatisfied with their present lot, they do not have ambitions towards which they might actually work in a constructive fashion, but daydreams, in which every thing is solved at once in a magical way, daydreams from which the emergence into reality is always painful. Any aid to the perpetuation of the state of daydreaming (or reverie, as Coleridge and De Quincy call it) is therefore greatly appreciated.”

Now there’s much I find compelling if not persuasive in this narrative, even if I would have arrived at similar conclusions from integrated post-Freudian and Marxist premises. The point being that a purely therapeutic approach, as such, to the drug problem does not get to the heart of the issue and reminds us why therapeutic acts of “intervention” and “rehabilitation” often fail. The “drug problem” is symptomatic of deeper societal/cultural issues which an “individualist” therapeutic regimen addresses only accidentally or incidentally or haphazardly. And this is not unrelated to the phenomenon of “medicalization” in our society, conspicuous instances of which are treated in The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into a Depressive Disorder (2007) by Allan V. Horwitz and Jerome C. Wakefield, and Christopher Lane’s Shyness: How Normal Behavior Became a Sickness (2007). As Horwitz (above) argues in Creating Mental Illness (2002), our current conceptions of “mental illness as disease” arguably fit only a relatively small number of egregious psychological conditions, and thus most of the conditions we regard as indicative of “mental illness” are cultural constructions (hence subject to the sort of ‘looping effects’ that Ian Hacking has well-described) of either “normal” responses to stressful social circumstances or are simply forms of deviant social behavior. Don’t get me wrong, I’m not a disciple of Thomas Szasz, nor part of any “anti-psychiatry” movement, and I’m especially opposed to faddish Freud-bashing (e.g., Frederick Crews). Indeed, I’m an ardent defender of the virtues of post-Freudian psychoanalytic theory and therapy. And I’ve been sympathetic to if not supportive of the “therapeutic jurisprudence” pioneered by David B. Wexler and the late Bruce J. Winick (see ‘references and further reading’ below). But a purely or even largely therapeutic approach to our drug problem strikes me as woefully inadequate.

Consider, again, this account from Dalrymple’s intimate and seasoned experience as a prison psychiatrist in England. He writes of being little acquainted with the “sudden expansion of opiate addiction” in his city, and that while he briefly ran a drug addiction clinic “in a famous university town,” “[o]piate addiction seemed to me neither important nor interesting:”

“But as more and more addicts came to my attention—when I was on duty in the prison, I would see as many as twenty new cases a day—I began to think about it more. The medical perspective, which coincided with their own, that these people were ill and in need of treatment, seemed to me less and less satisfactory or convincing. The number of drug clinics in the city increased dramatically, as did the amount of medication prescribed to addicts, but far from getting better, the problem only worsened.”

Dalrymple proceeds to describe in disturbing detail the physical and mental condition of the addicts in prison, concluding that

“If any director wanted extras for a film about a concentration camp, he would need to look no further than the daily entrants to British prisons. I used to remark to such young men that if they were released from prison in the condition in which they entered it, everyone would conclude, and rightly, that we were running not a prison but a concentration camp. Therefore, I said, it was only reasonable to conclude that, for them, freedom was a concentration camp; their own desires acted as the concentration camp guards. Badly educated as they were, lacking almost all knowledge of history or interest in current affairs, not a single one of them failed to understand what I meant, and they always laughed; they agreed with what I said. Freedom was bad for them, because they did not know what to do with it.

In fact, the great majority of them stopped taking opiates in the prison, even when they were available. (They were smuggled in by various methods, the most unscrupulous and emblematic of which was the use of little packets of heroin placed in the rectums of babies brought on prison visits by the prisoners’ girlfriends, and which would have killed the babies had they burst. …).

The addicts came into the prison starving and miserable, and went out healthy and happy. Within a few months, however, many of them were back to their former condition, and not a few of them begged the courts, when brought once more before them, to imprison them rather than let them to free. A strange world indeed, in which incarceration is preferable to freedom!”

It seems many of the addicts expressed to Dalrymple a belief more or less in the proposition that finding “a purpose in life was a sufficient condition to enable them to abstain. [….] The addicts themselves…acknowledged that their condition was [loosely and broadly] a spiritual one….”

Hence, the limits of a therapeutic approach, especially one that takes the form of an overly “medicalized” or “disease” (or physiological) response to addiction:

“I soon discovered that the medical services set up to assist addicts took on a technocratic attitude towards them and their problems. They focused on the physiological aspects of opiate addiction, since these were susceptible, at least in theory, to medical intervention, which in practice mean the prescription of a drug rather like the one the addicts were addicted to. And there was a strenuous, almost outraged, rejection of the idea that addiction was, at bottom, a moral problem, or even that it raised any moral questions at all. The addict was to be seen purely and simply as an ill person. And this meant that taking heroin was something that just happened to people rather than something that they did. In the process of turning the addict into a blameless patient, therefore, the doctors, nurses, psychologists, counselors, and social workers also turned an addict into something less than a fully responsible person, into someone not in charge of his own behavior, a creature or automaton effectively without choices, intentions, or even weaknesses. So uncertain of their own benevolence were these functionaries of care that they avoided all mention of the moral and spiritual aspects of addiction, since even to mention them en passant was to risk being perceived as condemnatory and therefore malevolent in intent. [….] Of course, it cannot be denied that opiate addiction has medical consequences, many of them very serious. [….] But medical consequences, however terrible, do not make a disease.”

I can’t do Dalrymple’s book justice here but this should suffice as a taste of the general argument. A similar argument with regard to alcoholism was made by one of my former teachers, Herbert Fingarette, in a controversial but equally important book, Heavy Drinking: The Myth of Alcoholism as a Disease (1988). It turns out that Dalrymple thought so too, for near the end of his work we learn “What Fingarette said of alcoholism can be applied with equal force to opiate addiction,” proceeding to quote a passage from Heavy Drinking in support of his contention that “the addict has a problem, but it is not a medical one: he does not know how to live. And on this subject the doctor has nothing, qua doctor, to offer.” Like both Dalrymple and Fingarette, I suppose I’m a moralist insofar as I’m concerned with the diminution of moral responsibility incarnate in the medicalization of addiction, and this in light (or the shadows) of what we might call mitigating socio-economic and cultural or environmental conditions in which individuals frequently fail to internalize a strong sense of such responsibility or are socialized so as to possess only a thinly attenuated sense of same. And I’m of religious or, better, spiritual suasion in as much as I think that, at bottom, this is in fact a species of that larger subject: “how to live,” and pivots upon questions concerning the “meaning of life.”

Finally, I’ll recommend a work that speaks to many of the issues broached here in a sophisticated and sensitive manner that endeavors to transcend a simple choice between “therapy” and “moralization,” namely, Mike W. Martin’s From Morality to Mental Health: Vice and Virtue in a Therapeutic Culture (2006).

Update (3/22/2011): Danielle has written the following comment to my comments at Concurring Opinions:

Dear Patrick,

Forgive me, but my post must have mislead you into thinking that Professor Boldt framed drug policy in the U.S. and U.K. as clean distinctions between a moral/criminal approach and a therapeutic one. The article offers a far more nuanced exploration of the complex interactions between culture and social practice, positive law and public health policy to get a better handle on how a given society negotiates the moral and practical features of the problem.
I would love your thoughts after you read the piece.

My best,

To which, I replied:


I didn’t assume that, but I thought the characterization of the “moral/criminal approach” was clearly pejorative: it’s not “pragmatic” it’s moralistic after all (and that’s always a bad thing among legal realists, i.e., most law profs), “the concerns animating drug policy in the United States are complex and anchored in moral judgments that may be difficult to dislodge” (perhaps such moral judgments are on the mark, even if inchoate or intuitive), “the engine of pragmatic reform will be dragged down by the moral understanding of drug abuse in this country” (again, moral understanding a liability here), and so forth. One might have drawn the inference that a morally-based view of drug policy is by its very nature not pragmatic.

Having read the part where you say “Boldt dispels the notion that ‘the history of drug policy in Britain and the United States served as ‘distinct perfect types, the former a nonjudgmental medical approach and the latter a morally tinged criminal prohibition approach,’ and that, “[i]nstead, the ‘reality likely was somewhat more complex and the similarities between the two more pronounced than might have seemed the case,’” I did not draw the inference “that Professor Boldt framed drug policy in the U.S. and U.K. as clean distinctions between a moral/criminal approach and a therapeutic one.” But the tenor of the post at least allows one to draw the inference that prevailing moral intuitions and judgments about drug use in our society inhibit possible or envisaged reforms and I doubt that is the case. And, in any case, I wanted to highlight the possible shortcomings of a “therapeutic” approach and, indeed, any of the current approaches on offer insofar as they are anchored largely in either “moralization” or “therapy,” failing to appreciate that the “drug problem” is symptomatic of wider and deeper societal problems of the sort Dalrymple mentions and insinuates above and I cited in the last sentence of the penultimate paragraph.

All the best,

References and Further Reading:

  • Aronowitz, Robert A. Making Sense of Illness: Science, Society, and Disease. Cambridge, UK: Cambridge University Press, 1998.
  • Bolton, Derek and Jonathan Hill. Mind, Meaning, and Mental Disorder: The Nature of Causal Explanations in Psychology and Psychiatry. New York: Oxford University Press, 2nd ed., 2003.
  • Cassell, Eric J. The Nature of Suffering and the Goals of Medicine. New York: Oxford University Press, 2nd ed., 2004.
  • Dalrymple, Theodore. Romancing Opiates: Pharmacological Lies and the Addiction Bureaucracy. New York: Encounter Books, 2006.
  • Elster, Jon. Strong Feelings: Emotion, Addiction and Human Behavior. Cambridge, MA: MIT Press, 1999.
  • Elster, Jon, ed. Addiction: Entries and Exits. New York: Russell Sage Foundation, 1999.
  • Elster, Jon and Ole-Jørgen Skog, eds. Getting Hooked: Rationality and Addiction. Cambridge, UK: Cambridge University Press, 1999.
  • Fingarette, Herbert. Heavy Drinking: The Myth of Alcoholism as a Disease. Berkeley, CA: University of California Press, 1988.
  • Graham, George. Disordered Mind: An Introduction to Philosophy of Mind and Mental Illness. New York: Routledge, 2010.
  • Hacking, Ian. Mad Travelers: Reflections on the Reality of Transient Mental Illness. Cambridge, MA: Harvard University Press, 1998.
  • Hacking, Ian. Rewriting the Soul: Multiple Personality and the Sciences of Memory. Princeton, NJ: Princeton University Press, 1995.
  • Hacking, Ian. Historical Ontology. Cambridge, MA: Harvard University Press, 2002.
  • Healy, David. The Creation of Psychopharmacology. Cambridge, MA: Harvard University Press, 2002.
  • Healy, David. Let Them Eat Prozac: The Unhealthy Relationship Between the Pharmaceutical Industry and Depression. New York: New York University Press, 2004.
  • Horwitz, Allan V. Creating Mental Illness. Chicago, IL: University of Chicago Press, 2002.
  • Horwitz, Allan V. and Jerome C. Wakefield. The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder. New York: Oxford University Press, 2007.
  • Lane, Christopher. Shyness: How Normal Behavior Became a Sickness. New Haven, CT: Yale University Press, 2007.
  • Martin, Mike W. From Morality to Mental Health: Virtue and Vice in a Therapeutic Culture. New York: Oxford University Press, 2006.
  • Mirowsky, John and Catherine E. Ross. Social Causes of Psychological Distress. New York: Aldine de Gruyter, 2nd ed., 2003.
  • Murphy, Dominic. Psychiatry in the Scientific Image. Cambridge, MA: MIT Press, 2006.
  • Radden, Jennifer, ed. The Philosophy of Psychiatry: A Companion. New York: Oxford University Press, 2004.
  • Sadler, John Z. Values and Psychiatric Diagnosis. New York: Oxford University Press, 2005.
  • Thornton, Tim. Essential Philosophy of Psychiatry. New York: Oxford University Press, 2007.
  • Wexler, David B. Rehabilitating Lawyers: Principles of Therapeutic Jurisprudence for Criminal Law Practice. Durham, NC: Carolina Academic Press, 2008.
  • Wexler, David B. and Bruce J. Winick, eds. Law in a Therapeutic Key: Developments in Therapeutic Jurisprudence. Durham, NC: Carolina Academic Press, 1996.
  • Winick, Bruce J. Therapeutic Jurisprudence Applied: Essays on Mental Health Law. Durham, NC: Carolina Academic Press, 1996.
  • Winick, Bruce J. and David B. Wexler. Judging in a Therapeutic Key: Therapeutic Jurisprudence and the Courts. Durham, NC: Carolina Academic Press, 2003.

[cross-posted at]