Friday, June 1, 2018

The Victim Meme In Addiction and Recovery

The popular press has created a victim meme in discussing addiction and the recovery process.  An example would be the popular quote from the NYTimes: "Only in death do drug users become victims. Until then, they are criminals".  I have problems with these quotes that have become memes in social media because the idea that people with substance use disorders are victims does not seem to originate in either the medical field and the physicians who treat them or the recovery literature written by the affected people themselves.  The other operative word in this quote is "users".  To me that means that nobody here is forced to initiate drug use or assaulted and forcibly given addictive drugs.

My first year as a psychiatry resident, I can recall a fellow resident presenting a patient to the senior attending.  He used the term unfortunate to describe the patient, a homeless middle aged man with a chronic psychosis and alcoholism.  The attending cut him off and said "What do you mean by unfortunate?"  In the next ten minutes or so, we learned that the patient was no more unfortunate than any of the other 20 men with severe psychiatric disorders on that unit. By extension the term was essentially meaningless, because it did not discriminate that person from any one else and it was irrelevant to the diagnosis and treatment planning. Years later, I learned it could also be an impediment to the treatment relationship.  A ban on smoking rapidly went into effect and the staff were split on what that meant. Many believed that it would result in more violence and aggression. Part of the ensuing rhetoric was "That is all that these unfortunate people have.  If we take smoking away from them - what's left?"  A very dim view of a person's life is required to see it as existence for the sake of smoking.  I would go so far to say it is blatantly dehumanizing.

The idea of patient as victims occurred again in psychiatry during the satanic ritualistic abuse phase and more recently during the patients are all victims of childhood abuse phase.  In the former case it lead to a proliferation of multiple personality disorder diagnoses and encouraging the proliferation of this myth with the associated unnecessary treatment.  In the case of treating everyone like a victim,  that program was correlated with an increase in aggression and staff assaults in state hospital settings and an eventual abandonment of the program.  Somewhere along the way, the application of a broad implementation of treatment based on whether or not a person is a victim is problematic from a programmatic standpoint, as well as the individual treatment relationship.

In terms of the individual evaluation, being victimized is a part of the clinical history.  Like grief, practically everyone has a history of some type of physical, emotional, verbal, or sexual abuse in the past.  The psychiatrists job is determining if it is relevant to the current problem and how it has impacted the patient's long term conscious state on an ongoing basis.  At a practical level it has resulted in an  ICD-11 diagnostic criteria set that identifies fewer patients as having PTSD compared with DSM-5.  From the linked reference it appears that there will be concern over identification of PTSD as well as under identification.  It is a more difficult task than just matching clinical criteria.  In many cases, PTSD symptoms recur in the context of depressive episodes and significant episodes of anxiety and resolve again when those episodes are treated.  In acute situations like intimate partner violence, advocates can provide a valuable function until a patient's living situation has been stabilized.  If victimization is a relevant clinical theme, it is addressed by addressing the associated syndromes and psychotherapy that is focused on maintaining safety, alleviating symptoms, and facilitating relevant lifestyle changes.           

Apart from victims the concept of the criminalization of the drug user is also a popular meme.  Simplified it is that drug users and alcoholics should be treated and not incarcerated.  It is based on the assumption that most of these folks are incarcerated on trivial drug or alcohol charges or probation violations from those trivial charges.  That can certainly happen.  Unfortunately real crimes involving loss of life, serious injury, and property crimes also happen.  I recently heard a District Attorney talk about the scope of the problem at the Minnesota Society of Addiction Medicine May 30 meeting.  He was keenly aware of the problem because law enforcement resources are currently flooded with opioid and methamphetamine users as well as people with severe mental illnesses.  He presented the problem to his prosecuting attorney and asked them to come up with a solution for people being prosecuted for drug crimes.   They ended up with a three step plan for sentencing offenders to maximize the likelihood of treatment and the ability to change felony crimes to misdemeanors after adjudication. The main message was that there is no interest on the part of prosecutors to incarcerate drug offenders, but there is clearly a limit with the associated crimes.

In the recovery literature, victim is rarely seen.  The Narcotics Anonymous book uses it in one place in the Eighth Step:  "Many of us have difficulty admitting that we caused harm for others, because we thought that we were victims of our addiction.  Avoiding this rationalization is crucial to the Eighth Step"  (p 38).  The AA 12 and 12 (2) contains the words victim in Steps 1, 3, 4, 10 and 12.  The term is used to make the general argument for powerlessness (Step 1), to discuss the effects of remorse and guilt (Step 3), to discuss the effects of erratic emotions (Step 4),  to illustrate the problem with resentments (Step 10), and how the program can free members from irrational fears (Step 12).  The bedrock of 12-step recovery is powerlessness and that is not the same thing as being a victim even though that word is used in Step 1. 

I don't think that I am going too far out on a limb in suggesting that the victim meme is not relevant in addiction, addiction psychiatry, or recovery. The importance of powerlessness as opposed to being a victim is captured from reference 2:

"Our admissions of personal powerlessness finally turn out to be the firm bedrock upon which happy and purposeful lives can be built."  (p. 21).

George Dawson, MD, DFAPA


For other variations on the victim meme see these previous posts:

The Whitening of the Opioid Epidemic:

Addiction Narratives Versus Reality:


1.  Narcotics Anonymous (6th Edition).  World Service Office.  California, USA 2008, p 38.

2.  12 Steps and 12 Traditions.  AA World Services, Inc.  New York City 2007.


  1. This comment risks more a reaction of outrage and being charged with insensitivity, but, after 30 years of medical school, residency, and being out as a solo practitioner, as well as years further as a member of society both as a citizen and being a member of a family, there are few times addiction can ever be framed as a victim. In all my years of living around addicts, I have yet to meet the person who has a muzzle print on his or her head enforcing abuse and/or dependency of a substance or behavior that meets the criteria to be labeled abuse or dependency.

    We ALL have choices, if we live in a society or organized communal group that allows choice, and at least here in America, we have the right to choice until proven otherwise. Thus, people have made the choice to experiment, use, and then abuse substances or involvement in behaviors that are dependency in outcomes. While there are exceptions, and I think random chance defines that number as about 5%, the other 95% know what they are risking by exposing themselves to a substance or behavior. It doesn't take a rocket science course, if one has any ability to reason and weigh risks and benefits, to know what can happen if the exposure is causing disruptions in health and function.

    Unfortunately, we as clinicians know that people will make further poor choices in exercising immature and pathological defenses in continuing their failed path down into dependency. But, again, no muzzle prints have magically appeared to claim complete lack of responsibility for consequences.

    And to continue my premise about choices, yes, addicts and people with dependency have the right to choose recovery or continued spiral down to despair and eventual premature demise. Unfortunately, the beast that is addiction/dependency does not make those choices easy, or, we would be without jobs for treating addiction/dependency, eh?

    I guess to avoid ranting further, I have come to realization that people who are in the grips of addiction or dependency that is dysfunctional need to realize, they are lucky that natural selection is not the inherent decider of their fates. No, the human condition as of this point of our existence has been very effective in limiting natural selection as an intervention. Otherwise, addiction would be a more limited experience among our species, because it would be a failure in promoting healthy evolution. And thus the process of unimpeded natural selection would weed out addiction in most likely an effective manner.

    So, maybe I offer this premise: have we been too caring, too empathetic, too invested in the disease model, to realize we are just risking the promotion of endemic impairment of our species?

    Not suggesting zero tolerance, and not suggesting rigid treatment interventions, nor suggesting abandonment, but, after what, a few hundred years of being confronted with fellow humans who are dramatically impaired from addiction and dependency, have we abandoned paradigms and inherent expectations to instead just promote covert addictions and dependency by the providers and invested significant others to addicts, that being making money, having power and influence, and perhaps unintentionally glorifying the inherent failure of codependency and enabling?

    Just some thoughts. For me, addicts need to choose recovery and function, or, eventually go the way of the Do-Do?...

    1. The genetic loading for alcoholism won't go extinct because the disinhibition of alcohol leads to unplanned pregnancy and the predisposition moves onto the offspring. Then said offspring are raised in an environment where drunk and volatile is part of the norm. In a way it's too bad that young people's vascular and hormonal systems are more resistant to alcohol-induced impotence.

  2. Always plenty of controversy about the family versus genetic effects. From my clinical experience apart from heredity, children are much more likely to be exposed to and use drugs and alcohol at an early age in many of these families. That can occur by intentional exposure to varying degrees and just being around after the party happens. In the end genetics + exposure is a bad combination.