Thinking beyond population harm and addiction

I often mention on this blog the range of problems that are associated with alcohol, and how this can muddy the waters when we try to discuss alcohol policy: are we worried about violence and antisocial behaviour linked to ‘binge’ drinking; health and social problems resulting from addiction or dependency; or the risk of health harm due to long-term use?

I was reminded of this yesterday for two reasons: a neat diagram I saw on Twitter from James Nicholls; and a conference I attended discussing the links between intimate partner violence and substance use, and how to address this.

James’ diagram showed a summary of how alcohol problems have been understood and the dominant policy approach taken by campaigners – for example, a belief in the 18^th century that spirits produced a new and dangerous type of drunkenness, and therefore that they should be specifically controlled (and perhaps beer consumption encouraged instead).

The example given for policy today was that campaigners have moved away from focusing on addiction as a disease (and therefore targeted treatment as a solution), towards a preference for understanding alcohol problems as being on a continuum, and the appropriate solutions as being focused on the supply of alcohol (e.g. price and availability).

The only problem with this way of thinking (and I’m not criticising James, just the public debate he’s analysing) is that if there’s a whole continuum of alcohol-related problems, it seems odd to focus on availability as the solution.

There is a strong argument that reducing availability affects use and therefore to some extent the scale of social problems associated with substances.  A key reason (though not the only one) why there aren’t that many heroin users in Britain, and there are far fewer heroin-related deaths than alcohol-related deaths is that it’s not as easily available.

(Of course heroin us isn’t as socially acceptable as alcohol use, but again the two things (availability and a culture of consumption) are linked: alcohol is available all over the place – and supported by politicians as an industry – because it’s socially acceptable, but it’s acceptable (or normal) partly because it’s so visible and available.)

But all that doesn’t mean that availability is the only game in town; it’s certainly not what most drug campaigners focus on.  Whether you have a relatively free market in substances, one that’s reasonably well-regulated, or one based around prohibition, you’ll still have people using substances who need some form of help to reduce the health and social harm caused by their use.  Current treatment services in the UK have plenty of users of both alcohol and heroin.

You can call that level of use ‘addiction’, or ‘dependency’, or ‘heavy use sustained over time’, or you might be thinking of ‘risky single occasion drinking’ – and all those might describe genuinely different patterns of use that imply a need for different sorts of support.

And that’s where the debate in the UK has fallen down.  There’s a tendency to leap to see either the substance (alcohol) as the problem, or identify particular people (alcoholics, drunks, or whatever label is in fashion) as having weaknesses or vulnerabilities to it.  In the 20^th century stage of James’ model, although it isn’t seen as a person’s moral failing, particular people are picked out as having a ‘disease’.

There’s always an issue around stigma, though, when you focus on individuals.  Kettil Bruun argued that focusing on populations was a neat way to get around this – and you could still implement interventions on this basis that were effective for those most in need of help.

Some current commentators on substance use (notably Johann Hari) have tried to bypass this debate by plonking down (without admitting it) the old sociological concept of ‘structure’ to replace the ‘agency’ of the individual who might have a problem.  That is, it’s suggested that the problem doesn’t reside in particular substances (and people often replace an ‘addiction’ to one substance with some other form of addiction – to activities like shopping, sex or gambling as much as substances).  Instead, with frequent reference to ‘rat park’, the wider social environment is seen as the problem: people who have issues with substances variously need ‘jobs, friends, houses’ or social ‘connection’.

In reality, this doesn’t get us out of the debate on whose ‘fault’ addiction is, as any sociologist who’s tried to write about structure and agency would be able to tell you.  (Don’t get me started on Anthony Giddens and ‘structuration’.)  The reality is bound to be more complex, where some people’s issues will be primarily down to their social environment, others a genetic predisposition, others simply to the risks inherent in alcohol consumption, where they didn’t particularly have any other warning signs.  Most are a combination of a whole range of factors.

And this formulation still leaves us focusing on a particular cohort of people: those who are (whether we use the word or not) ‘addicted’.  And even if you’re not saying that individual has a moral or genetic ‘failing’, there’s still something stigmatising about pointing out which group in society is in greatest need of jobs, friends and houses, and social connection – and there’s a danger this plays into certain damaging narratives around ‘sink estates’.  When you hammer home the importance of wider social structure, there’s not much ‘agency’ left to that individual to find meaning and stop feeling powerless in their own life.

But what’s this got to do with intimate partner violence (IPV) and yesterday’s conference?

Well, you can see the ‘jobs, friends, houses’ narrative as having just the same aim as Kettil Bruun’s population-wide approach: make sure resources are there for those who need them most.  Only in this case, it’s a response to the fact that the population-level approach seems to be shifting attention from those with the least ‘recovery capital’ to those with the most: brief interventions and universal efforts to reduce everyone’s consumption just a little bit.  By reminding us of the need to focus interventions on those who actually need jobs, friends, houses, we can target scarce resources most effectively.

(I should point out that this is only my speculation on the motives of some who’ve made these claims; probably not Johann Hari, who’s more concerned about stigma and a more liberal drugs policy.)

But as we talk about jobs, friends, houses (I know it’s getting tedious repeating that phrase) we’re really just talking about ‘addiction’ or ‘alcoholics’ in a new language.  We’re still focusing on one particular segment of a broader spectrum of problems.  And that poses a big problem for some of the possible responses to IPV that were discussed yesterday.

It was pointed out that while programmes to treat perpetrators of domestic abuse mostly run through criminal justice services, only a small proportion of those who commit these acts come into contact with the criminal justice system, and still less for these specific crimes, which is how people come to be referred to these programmes.  By contrast, a high proportion of those in substance misuse treatment admit to having committed IPV (though they wouldn’t necessarily see this as a crime, particularly where it doesn’t involve physical abuse).

This is the logic for hosting such programmes within substance misuse treatment services, or at least referring people through them.

And research with the partners of perpetrators that was presented at the conference by Ingrid Wilson suggests that alcohol is indeed closely related to IPV.  (And I have to say I thought her model of the stages of drinking and IPV was one of the best results of a grounded theory type approach that I’ve seen.)  But I’d suggest that the drinkers described by their victims had more in common with ‘binge’ drinkers – or perhaps those who engage in “frequent occasions of heavy drinking that [also] result in heavy volume drinking”.

And those are the people who don’t fit into that binary debate of population-wide or targeted measures, as long as we see the ‘target’ of treatment so narrowly.

If we really think there is a continuum of harm in relation to substances (and alcohol in particular), then we need to think of a full continuum of interventions.  And that means having more nuanced discussions than we do now.  Binary thinking might help frame some discussions, and will win some arguments, but it can’t give the full picture, or provide a complete answer.