I argue here that Addiction Services that are abstinence focussed inhibit therapeutic change.
A broader perspective needs to take into account the client’s relationship with the culture of addiction as one possibility for what is an essential socialisation, but a possibility open to alternatives and change. In other words if the client does move away from the culture of addiction, how can it be replaced by an alternative and does this require some fundamental changes in the client’s sense of their place within the new culture or symbolic network., i.e. a change in subjectivity or neo-subjectivity.
The ‘addict’ can present as an ‘underground hero’, with a degree of ambivalence and ambiguity, with The Prohibition creating jouissance, a sense of hard to symbolise pleasure/excitement derived even from pain, from the act of doing something prohibited, officially illegal. This creates various not exclusive possibilities: the ‘need’ to use to prevent withdrawal symptoms and the nature of the possible symbolic relationship(s) that the addict has with the drug itself,
This sets up two extremes neither ever wholly and solely true but both always materially effective, namely two gendered possibilities. The psychoanalyst Lacan describes the individuals power relation to an ideology as a gendered ‘sexuation’ that is not bound to a biological sex. The masculine is wholly enflamed by the symbolic structures but feels powerless and strives to have power by feminising the ‘Other’. The feminine is not wholly enflamed by the symbolic and is ‘not-all’ an object of mystery for the masculine, and who feels a desire to be of service to the masculine. The gendered relationships her firstly, is with the drug as an object of value for the addict, “I enjoy it….” or secondly, the addict as an object of value for and working for the drug: “it’s holding me back…”. The relationship with the substance misuse service is judicially determined by the abstinence rhetoric and feminises the client as external to (or at least not fully captured by) the symbolic network and pathologised judicially as an ‘addict – criminal or patient’. Alternatively the client can be given gendered options by the service, (which is a Lacanian psychoanalytic approach) to examine the nature of the relationship with the drug and the service. The relationship with the addiction is one with a socialised intersubjective culture, and also one with its own phantasmic structure and relationship with an Other, a Look (Sartre), as part of a scene as if observed. The behaviour may be perceived as pleasing for the Other accruing admiring praise, or it could be perceived as creating pain anxiety or anguish for the Other. The behaviour is part of a human drive emerging from the constitution of subjectivity as it emerges through language as either a masculine complete submission to the symbolic resulting in a powerlessness, but ‘with its escape clause’, a fantasy that there is an Other, the primal father who does have all the power; or a feminine emergence from the oedipal process as not completely contained within the symbolic, a part has escaped, so that she does not fully exist within the symbolic and is structured against the masculine for whom (?stereotypically) she may desire to be an object of value.
Clinically an early key issue is the nature of the client’s relationship with the addiction, what is addiction? are they ‘addicted’?, is the drug of value to them? e.g. do they control the drug (and why?), or, are they of value to the drug, does it control them? An issue is whether losing the addiction will lead to its replacement with a different object of ‘addiction’. Is the relationship hystericised (feminine, repressed and disavowed, which is common) or is it perverted, the role played of the ‘underground hero’, the masculine role of the Father of Enjoyment who knows the things to be known but who may also paradoxically be acting out rage against his or own femininity, by feminising others. Is the aim of analysis to disrupt or to stabilise the client within the symbolic network or culture of addiction.
The ethos of the service may demonise the addict as the Heroin-Thief, who has metaphorically stolen our enjoyment, stolen our Heroin, who must pay us back, by providing us with their alway assumed to be heroin infused urine, so that, in the process we feel a libidinal gratification.
The current funding indicators and official policy promote abstinence, investing the service with a gendered masculine role in relation to the clients, this will either reinforce the hysteric, or set up conflict with the pervert; in either case it forecloses possibilities for change. This abstinence culture creates several roles for the clinician: a role that is seen by some clients as a supportive ‘dealer’ providing something for nothing, or as an insurance salesman providing something for nothing, and/or as a policemen simply interfering with the addicts smooth symbolic functioning. None of these roles permits effective exploration of possibilities for changes in the client’s relationship with the addiction culture/society. Effective work with clients, at least work capable of promoting change if it is desired by the client should therefore avoid an abstinence driven culture, and focus more on exploring the client’s signification in relation to his addiction culture.