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
Supplementary:
For other variations on the victim meme see these previous posts:
The Whitening of the Opioid Epidemic:
https://real-psychiatry.blogspot.com/2018/05/the-whitening-of-opioid-epidemic.html
https://real-psychiatry.blogspot.com/2018/05/addiction-narratives-versus-reality.html
References:
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.
