Drug treatment and rehabilitation
in The Netherlands
DRUG AWARENESS AND ADDICTION PROGRAMME
21-25 SEPTEMBER, 2015, AMSTERDAM
Frans Koopmans (De Hoop Foundation)
Monday, September 21, 2015 (13.00-14.00)
Good afternoon, ladies and gentlemen,
First of all, I want to thank the organizers of this EURAD ‘Drug awareness and
addiction programme’ to be able to share with you some thoughts on the subject of my
speech: ‘Drug treatment and rehabilitation in The Netherlands’.
Let me first introduce myself: my name is Frans Koopmans. Since 1987, I have been
working at De Hoop Foundation (The Hope) in the Netherlands. De Hoop is an
abstinence based Christian psychiatric hospital for addiction care. Since 1975, we have
been helping hard drug, alcohol, medicine and gambling addicts on the way to a life
free from addiction. My own specialty lies in the study of addiction and addiction
policy.
Introduction
In dealing with substance use and addiction, two approaches can be thought of.
Rehabilitation and punishment. Two approaches of addiction that at first glance seem
mutually exclusive. Rehabilitation aims at restoring the addict to good health or a
useful life, f.e. through therapy and education. This approach often starts from the
premise that addiction is primarily a health problem. Punishment, on the other hand, is
imposing a penalty for wrongdoing, in this case the use of illicit drugs resulting in
addiction, where the basic premise is, that addiction is a legal problem. As I said, they
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seem mutually exclusive. However, in reality, both approaches go together.
Punishment can be part of rehabilitation, and vice versa: rehabilitation can be part of
punishment. The two approaches do start, though, from different perspectives as to
what exactly constitutes the origin and nature of addiction and drug use.
Drug use and addiction are, then, remarkable phenomena. One may well wonder how
the same phenomena can be addressed punitively as well as medically. Harvard
professor Gene Heyman in his 2009 book ‘Addiction, a disorder of choice’ writes, and
I quote:
[quote] “We typically do not advocate incarceration and medical care for the same
activities. Indeed, addiction is the only psychiatric syndrome whose symptoms – illicit
drug use – are considered an illegal activity, and conversely addictive drug use is the only
illegal activity that is also the focus of highly ambitious research and treatment
programs.” [end of quote]
Drug use and addiction have a legal as well as a medical side to them simultaneously.
Which side prevails in drug policy depends on the specific view that one holds of the
nature of drug use and addiction, the person of the addict and the circumstances in
which addiction and drug use take place: a public health approach when one regards
addiction predominantly as a health issue, a legal-punitive approach when one regards
addiction predominantly as an illegal activity. Underlying this dilemma is the question:
can an addict really be held accountable/responsible? The answers differ, depending
on the perspective one uses.
In my presentation, I will try to delve somewhat deeper into this dichotomy of
rehabilitation versus punishment. My lecture will consist of the following:
1. Bird’s-eye view of different perspectives on addiction
2. Ways out of drug abuse – some suggestions
3. Drug treatment in the Netherlands
4. Concluding remarks
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1. Bird’s-eye view of different perspectives on addiction
Let me first state that the addiction problem with which we are confronted today of
course cannot simply be brought back to the aforementioned polarized positions of
rehabilitation or punishment. Addiction is a multifaceted problem that includes more
than either health or legal considerations, important though they be. The basic problem
with addiction policy and addiction care seems to be that there have been and still are
widely divergent perspectives on what addiction in fact is, i.e. what its defining
characteristics are, as well as what would be appropriate responses. Historically, there
have been different views as to what exactly constitutes the essence (the origin, nature)
of addiction and the addiction problem (Van den Brink 2005). As a result of this,
addiction was and is dealt with in different ways.
Since the mid-18th century there was a change in the way addiction and addicts were
regarded. At first, addiction was primarily seen as a moral weakness: the moral model.
The addict (the one showing habitual drunkenness) is weak and a-moral, i.e. morally
wrong. As from practice it is clear that he not a automaton and is able to refrain from
taking drugs or drinking alcohol, there is sufficient reason not to seek and use
drugs/alcohol. This latter intentional behavior points to the fact that one may morally
assess this phenomenon. That is to say, may be the object of evaluation regarding
responsibility. The normative criteria of this responsibility are a general capacity for
rationality and a lack of unjustified compulsion (Morse, 2004). The solution for the
addiction problem within this paradigm was sought in prison or a re-education camp.
Though the view of addiction has been a-moralized over the last couple of centuries,
there are still proponents of this model to be found today.
With the rise of medical science in the second half of the 19th century, one gradually
came to see the addictive substance as the main cause for addiction: the
pharmacological model. The kernel of the problem was now seen lying in the
substance, not in the person. The solution for the addiction problem was now sought in
prohibiting the addictive substance . By prohibiting the addictive substance it would
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not be readily available. In the 30’s of the previous century, subsequently, this
pharmacological model, though politically still in place, was gradually replaced by a
model that emphasized that addiction was to be regarded as the symptom of deeper
underlying personality or character problems. Those problems needed to be addressed
by psychotherapy: the symptomatic model. The addict is suffering from a personality
disorder. Psychotherapy, for example in therapeutic communities, is seen as the
appropriate solution, aiming at furthering understanding in the addicted person.
In the period 1940-1960’s, the disease model gained popularity: addicts are those
persons who are – compared to not-addicted persons and based on their biological and
psychological characteristics – much more vulnerable for addiction. “According to this
model, there are fundamental (premorbid) biological and psychological differences
between addicts and non-addicts. Therefore, the former are not capable to use drugs
and alcohol moderately.” Addiction is described in terms of loss of control and
physical dependence (‘tolerance’, ‘withdrawal symptoms’). The solution is seen in
lifelong abstinence, for example via self-help organizations as Alcoholics Anonymous
and treatment based on the Minnesota Model.
From the 1960’s onwards a new psychological perspective on addiction came to the
fore: addiction as a form of learned behavior: the learn theoretical model. Basic to this
perspective is that behavior that has been learned, can also be ‘un-learned’, including
addictive behavior. The therapeutic approach is here in the form of cognitive
behavioral therapy and cue-exposure therapy.
What the perspectives mentioned above have in common, is that one focusses on one
aspect of addiction, that is subsequently being seen as explicative for the problem.
Increasingly, however, the awareness gained ground in the 1970’s and 1980’s, that
restricting the explanation of addiction to just one of its aspects doesn’t do justice to
the multidimensional nature of addition. This concept of a multidimensionality of
addiction meant an adjustment – even correction – of the one-dimensional approaches
that had been prevalent up till then. Researchers and treatment providers alike realized
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that in order to gain a more truthful, more integrated picture of addiction all relevant
aspects of addiction should be taken into account simultaneously. One discovered that
apart from biological and psychological causes, also social circumstances play a role
in the development of addiction. This finally led to the bio-psycho-social development
model, that we have today. The model holds that for the development of addiction,
apart from the addictive substance, not one cause can be given, but that different
factors at the biological level (i.e. genetic predisposition), the psychological level (i.e.
dysfunctional thoughts and behaviors) as well as at the social level (i.e. disturbed
relationships, problems with housing) determine whether someone becomes addicted
or not. In order to address the addiction problem one needs to take into account all
these levels via multimodal (integrated) interventions.
Since the 1990’s there seems to have occurred again a return to a much more onedimensional approach towards addiction: addiction as being primarily a brain disease,
i.e. a making absolute the ‘bio’ aspect of addiction. On the waves of brain research,
research into addiction now predominantly consists in brain research.
Table 1: Short history of the concept of addiction1
Period
Dominant Addiction
Matching treatment
Model
1750-now
moral model
prison, re-education camp
1850-now
pharmacological model
Prohibition of alcohol and drugs
1930-now
symptomatic model
psychotherapy en therapeutic communities
1940-now
disease model
Medication and AA
1960-now
learn theoretical model
(cognitive) behavioral therapy
1970-
bio-psycho-social model
multi-modal therapy
brain disease model
Medication and (cognitive) behavioral
1990
1990-now
therapy
1
Based on (Van den Brink, 2006), 60
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But can we say now that we have seen the light and that, yes, addiction is indeed a
biomedical problem, a chronic relapsing brain disease? Even though the majority of
addiction scientists now submit to this model, the question is far from being settled.
The question what constitutes addiction is, as far as I am concerned, still not answered.
And perhaps even cannot be answered conclusively. One of the problems with
emphasizing one aspect of the addiction problem is neglecting other equally relevant
aspects. In scientific literature, there are almost as many perspectives as there are
addiction scientists. Each of these perspectives in principle provides legitimate, though
inevitably from the nature of things, limited views of what constitutes addiction.
Emphasizing specific aspects of addiction and neglecting others may hamper an
integral, comprehensive (‘holistic’) view of addiction.
To get back to rehabilitation or punishment, or rehabilitation instead of punishment:
we have seen that there are many more perspectives than just the biomedical or the
punitive ones. Still, for our discussion they can serve as examples. Both provide a
specific interpretation of accountability: the question whether an addict can be held
responsible if he does something wrong, or that that is not the case; because the addict
suffers from a chronic relapsing brain disease which negatively influences his capacity
for decision making and behaving morally. There is a lot of literature dealing with this
question, also in the broader discussion whether you and me are completely
determined by our brains. For if that is the case, the ultimate conclusion has to be that
you cannot be held accountable. ‘For my brains did me do that…!’
Disease model
Elementary to a disease model of addiction, is the notion that addictive behavior is
compulsive. Compulsion is doing something because one experiences one has to do it.
The urge is irresistible. One does the specific act repeatedly and is unable to stop it. It
is not something that you do out of free choice. So, where addiction is defined as a
‘chronic relapsing brain disorder’ compulsion is central. The idea is that addicts,
because of their addiction and the inherent lack of concern for their health are viewed
as being mentally incompetent to make real choices or to consent to whatever. They
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suffer from decisional impairments, from invalidating decision-making capacities.
Disease, then, seems fully incompatible with the responsibility of the addict. Perhaps
responsibility for the disease of addiction can be applied to the beginning stages of the
disease. But ‘disease’ consists of irreducible, pathological mechanisms in the body
over which conscious choice does not have sway. “The signs and symptoms of the
disease […] are seemingly the mechanistic consequence of pathological biological
structures and functions over which the addict has no control once prolonged use has
caused the pathology.”
Connected with compulsion, is the opinion that addicted drug-users contravene their
true desires. One has to differentiate here between so called first and second order
desires. According to Harry Frankfurt “addicts are not free because they have a first
order desire to take heroin but a higher second order desire not to desire to take heroin.
[…] Freedom of the will occurs when our first order desires are in line with our second
order desires: we do what we desire to desire to do.” In the case of the addicts, from
the perspective of the disease model, one can speak of autonomy impairment. There is
a conflict in the volitional hierarchy of the person: the person does something that he
really does not want, so he acts against his will: “Addicts change their minds: the
opportunity for consumption arises, or the cravings begin, and the pleasures of the
drugs begin to weigh more heavily with them than the goods achievable through
abstaining.” So, the addict seems to sacrifice his longer term interest by giving in to
his shorter term interest, i.e. the use of drugs. Even though he might originally have
opted for the longer term interest, there occurs a judgment shift in the addict where he
ends up in choosing for the immediate gratification of the desire. The latter seems to
him at that specific point of time to be more ‘rational’ than choosing abstention. By
sacrificing his shorter term interests for the longer one, he would have been capable of
pursuing his own conception of the good.
Levy (Levy 2006b) describes the addict as a less unified self, as somebody who is
unable to effectively exert his will across time, as somebody who is lacking the
capacity for self-government, which shows itself in preference reversals. Lack of an
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unified self can be compared to the empirical experience that addicts stop their normal
development the moment they start using drugs. Their selves are more fragmented
(‘disunified’): “They lack the capacity to unify themselves to a sufficient degree to
begin to formulate plans and policies, in the realistic expectation that they will abide
by them.” And so they are less able to delay gratification. Levy (Levy 2006a; Levy
2006b) brings in here the notion of ego-depletion. Even though he does not fully agree
with the notion that addiction destroys all autonomy, he still holds on to a certain
measure of autonomy impairment: “After all, not only is there the phenomenological
evidence, to which many of us can attest, that breaking addiction is difficult, there is
also the evidence that comes from the fact that addicts slowly destroy their lives and
the lives of those close to them.” Ego-depletion, Levy states, causes self-control over
time to diminish. The length of time this takes depends on how much self-control
resources are there in the life of the addict and how much of those resources are spent.
What addicts need to do, then, is take care to avoid cues that trigger craving. For,
within the disease model, it is the craving that makes addicts give in to their first order
desires and thereby squander their true good. Addicts still have some basic autonomy,
Levy holds, “the minimal status of being responsible, independent and able to speak
oneself.” But where true autonomy (or: ideal autonomy; or: maximal authenticity)
consists essentially in the exercise of the capacity for extended agency, addiction
undermines this “so that addicts are not able to integrate their lives and pursue a single
conception of the good.” Caplan (Caplan 2008) holds that an addict might be capable
of, what he calls, reason-autonomy, that is being able to make decisions, setting goals,
etc. But according to him this is not sufficient for autonomy. “Being competent is a
part of autonomy, but autonomy also requires freedom from coercion.” This would
make (temporary) infringement of autonomy possible in order to restore long term the
autonomy of the person!
Does addiction create a defect of the will? A defect of the will means that the actor
cannot choose otherwise. This only counts when the actor’s choice is inconsistent with
his ordered preferences, with his higher desires, so: against his will. The addict knows
the choice he ought to make, he also wants to make that choice, but he is unable to
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take the course of action or it is unreasonably difficult for him to do so. So, it seems to
be a matter of compulsion, the state that addicts literally cannot resist their urge to
procure and take the drug. However, does compulsion really exist? Levy denies this.
The idea of the unwilling addict is a myth, he states. There is no such person “because
there is no such thing as an irresistible or compulsive urge to consume drugs, and
because the addict who is moved by a force which is wholly alien to her is a myth.”
Addiction provides the motives for action, certainly, but that is not equivalent to
saying that those motives are irresistible (i.e. compulsive). The addict is not helpless.
Summarizing, we can say that a disease model of addiction emphasizes compulsion
and loss of control that seems hard to equate with full blown autonomy. Instead, it
advocates a position of non-autonomy or, at best, reduced autonomy.
Disorder of choice model
Basic to a disorder of choice model is that – contrary to the disease model – addiction
is not compulsive. In a disorder of choice model, one holds to the notion that addicts
are morally responsible persons who are quite able to make rational, volitional choices.
As Foddy & Savulescu (Foddy and Savulescu 2006a) indicate, “the evidence that drug
users do in fact respond to powerful incentives is a strong indicator that their behavior
is not compulsive”. As also Levy (Levy 2006b) points out, “[I]f addictive desires were
compulsive, it is difficult to see how addicts could give up voluntarily”. And when
addiction is not compulsive, i.e. when addiction/addictive desires is/are not irresistible,
it follows that addicts cannot be regarded as ‘mindless automata’ that are forced to act
on the basis of the cravings the lack of drugs produce. And when the desires are not
irresistible, it means that addicts are not deprived of their possibility to make volitional
choices.
In an earlier article, Levy (Levy 2003) states that the core issue of (the continuation of)
addiction is not craving or compulsion; the use of drugs is better explained by the
mechanism of hyperbolic discounting, by existential dependency and by life problems.
The first refers to the mechanism that rewards that are closer to us in time gain the
preference over the rewards that are more long term. The second points to the fact that
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the addict forms his life around the drug, and that the drug in its turn provides the
framework for living. The last refers to the observation that the consumption of drugs
is a way to deal with life’s problems, only “an extremely flawed solution.”
According to Foddy & Savulescu (Foddy and Savulescu 2006a), addiction is not really
much different from drug-oriented and other appetitive desires, like eating, only it is
stronger. And whereas appetitive desires must be considered valid sources of rational,
volitional choice this also applies to chemical addictions. So, in their opinion, choices
of addicts, even when desiring drugs, are authentic choices: “It may be that desire for
drugs harms a person or leads a person to do what he has good reason not to do, but we
should not say these desires are unreal or inauthentic.” Within a disorder of choice
model a conclusion can be upheld that, contrary to a disease model, addiction is not
compulsive and that addicts keep on exercising some degree of control over their
consumption behavior. They are still in the possession of their volitional resources.
Addictive behavior is intentional behavior, i.e. the addict plans, purchases drugs,
consumes them, etc. And all these acts are deliberate acts. And that is equivalent to
saying that it is his choice to do these things. “That is precisely what makes addiction
such an interesting issue in the study of responsibility: the addict knows what she is
doing and chooses to do it, and yet we want to say that, in some sense or other, she is
not in control of her behavior.”
Even when we would recognize disease elements in addiction – which in our opinion
can be admitted – “[t]he presence of a disease per se does not answer the question of
responsibility within a moral and legal model, even if the presence of the disease and
its signs and symptoms are uncontroversial.” One can even admit, with Levy, that
there is a measure of autonomy impairment in the addict. But how does one measure
the impairment of autonomy? As Husak (Husak 1999) holds, “the amount of
autonomy that must be lacking in order to excuse an act may not be identical to the
amount that must be lacking in order to justify its proscription.”
Contrary to a disease concept, within a disorder of choice model addicts are not
regarded as automatons. That is to say, addicts are not determined to (continue to) use
drugs. When an addict is able to make other choices, it means he is not determined,
that he is free to choose. Corrado (Corrado 1999) differentiates as to a defect of the
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will between those who hold to the notion and those who don’t. The first are those
who hold that the person cannot choose otherwise, which he equates with the position
of the disease theory of addiction. Those who hold the latter position (i.e., that there is
no defect of the will) he subdivides in those who hold to rational addiction (addiction
is just behavior as any other, rationally pursuing an increase in pleasure (or utility),
and so has no bearing on responsibility), addiction as duress (addiction is a rational
response to a coercive situation and so is not responsibility after all; addiction serves
as an excuse, rationally avoiding pain) and addiction as distortion, as a defect of
rationality (the addict’s behavior is irrational in the sense that he brings about
consequences that he would prefer not to bring about, and fails to bring about
consequences he wants to bring about. So, his beliefs do not respond to the evidence,
distorting the addict’s relationship with reality).
A disorder of choice model denies the metaphor of ‘mechanism’ within the disease
model as “the most misleading source of the intuition that some people cannot control
actions intended to satisfy some desires, especially if we believe that the desires are
produced by neurochemical or other brain abnormalities.” Morse, referring to
Odysseus, argues that the addict has a duty to take steps to bind himself to the mast
“when his desires are less insistent, especially if the addiction-associated behavior is
legally forbidden or if the costs are externalized because the behavior harms families,
friends, and society more generally.”
Up till now in western democracies, the Law in general also does not regard addiction
– and this applies perhaps to most mental and physical diseases – as something that
exculpates the addict when committing criminal offences. The courts have not excused
the addict’s behavior as non-responsible. And that is equivalent to saying that
addiction is not regarded as a disabling condition. And even when it would be
conceded that addiction does infringe on responsibility (i.e. does result in volitional
impairment), it seems impossible for the Law to point out where to draw the
demarcation line. Law does not base itself on the latest biomedical research. The latter
cannot tell how the Law ought to respond. The law as an instrument of social control
must be kept in place.
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Within a disorder of choice model addicts are responsible for their addiction and for
the behavior connected with it. It is the addiction that motivates the person to act. And
the way he does that, is remarkably similar and familiar to the way any human being
acts. “They engage desire, because they promise rewards for drug-ingestion, and
because they promise relief from pain, physical and psychological, whether the pain
that often leads addicts to seek out drugs in the first place, or the pain that is the result
of drug-withdrawal. Addiction provides strong motives for action, but there is no
reason to believe that these motives are irresistible.”39
A disorder of choice, then, negates the compulsiveness of addiction and adheres to the
conviction that addicts make volitional choices, also when choosing to procure and use
drugs. The model recognizes that addicts can be regarded as autonomous in the latter
sense.
Summarizing: there are enough considerations to underpin the notion of responsibility
in the case of addiction. Even though the capacity of responsibility and accountability
may be reduced, the addict is still capable of making volitional choices. That makes
him morally responsible. And that means that punishment may be accorded when
necessary.
Model of existential dislocation (Alexander 2008)
Still, not everything has been said. For even when taking into account the medical
aspects of the addiction as well as the volitional aspects of addiction, we are in danger
of making the so called mereological fallacy: the fallacy of confusing the part with the
whole (or of confusing the function of the part with the telos, or aim, of the whole).
Applied to addiction: saying that de medical aspect is the addiction, or that the choice
aspect is the addiction . We should in my opinion hold to the notion that addiction is a
phenomenon concerning the whole person. And therefore that addiction can be
explained by the term ‘dislocation’, even ‘existential dislocation’. Dislocation stands
for detachment, disengagement, being broken from the moorings. Over against
‘dislocation’ stands ‘psychosocial integration’. But not just psychosocial, I would
submit, but also existential. The existential notion is prevalent here. Like a disorder of
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choice model, this model acknowledges the fact that addicts are morally responsible
agents. They are not victims of their disease, they are not suffering from a compulsive
disorder and they are not forced to use drugs. In an existential dislocation model we
recognize that addicts take drugs because they want to (so, constitutes a volitional act).
Still, their own testimony is that they use against their wills. Levy understands this
unwanted addiction as characterized by an oscillation in the preferences of the addict.
The experience of craving induces a judgment shift in the addict. Still an existential
dislocation model does recognize that more is at hand than just disease or choice.
Within this model addiction is a way to cope with life’s basic issues. That is equivalent
to saying that addiction is in-depth an existential problem, a way of trying to cope with
dislocation.
Both a disorder of choice model as an existential dislocation model refuse to
acknowledge the notion that addiction is equivalent to the hijacking of the brain, as is
assumed in a disease model. In the latter model, in the case of addiction, there is an
impairment of autonomy. The first two models substantiate their view by pointing out
that were addictive desires compulsive, no addict would give up voluntarily. But the
fact is that they do. (Levy 2006b), (Heyman 2009). Where loss of control in a disease
model seems to be connected with non-culpability, in an existential dislocation model
the element of responsibility is upheld. It holds that ‘loss of control’ as an independent
state or condition that undermines responsibility does not gain much support from
related scientific or clinical data. In an existential dislocation model addicts are held
responsible for their addiction and for the behavior that they commit under the
influence. As Watson writes: “Even if addictive conditions are in some (not yet well
understood) way responsibility-undermining, addicts are complicit in their own
impairment.”. And a few pages later: “Citizens have a standing legal duty to develop
and maintain sufficient capacities of self-control to enable them to conform to the
law.”
In an existential dislocation model the possibility of moral choices within an
existential framework is held onto. And with this the dignity of the human being as a
responsible creature. Carrying responsibility is what honors a human being as a human
being. In a disease model the addict is sometimes regarded as a victim. But when the
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addict does not experience the consequences of his own, freely chosen actions, or
when the consequences of his actions are either removed or softened, this can be seen
as incompatible with truly human flourishing. Human life is worth the name where
people who voluntarily engage in specific kind of acts, also experience and are
responsible for the consequences of those actions. Herein consists the dignity of the
human being: that he is a responsible person and can be held accountable for his
actions and the results of those actions. Removing the consequences is equivalent to
diminishing the dignity.
Addressing addiction asks for more than a technical solution to the medical problem. It
means that questions need to be answered as to the purpose of human existence, the
existential questions regarding human life, the questions as to why somebody wants to
avoid pain and pursue pleasure as the highest purpose of life. And such questions can
only be answered by those who have asked those questions first of themselves. One
might even endeavor to say that, in the end, addiction is problem of the heart. But
when the addiction problem is reduced to its technical dimensions, the heart is lost
sight of. Addiction seems much more to be an existential problem. As Dalrymple
remarks: “The addict has a problem, but it is not a medical one, it is an existential,
spiritual one: he does not know how to live.” And when addiction is not a medical
problem, medical interventions will not solve it. Addicts will have to be given a reason
for living.
Dalrymple’s remark points towards a central element in the existential dislocation
model. Even when there would be a (partial) recovery of autonomy, when this
autonomy is not connected with the experience of ‘belonging’, of ‘liberation’, this
concept remains empty. That is to say, when the dimension of meaning is left out of
the discussion, at best we will arrive at superficial solutions that do not do justice to
what a human being is. In a disorder of choice model, these existential notions of
addiction are not part of the concept, just as they are not part of the concept of a
disease model. Only within a model that addresses these deeper issues, justice is done
to what addiction is all about. In an existential dislocation model room is made for
these existential questions that are elementary to addiction, by including spirituality as
a factor in the understanding and treating of addictive behaviors. Here, addiction is
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concerned with the way in which relationships are disordered by making a particular
substance or behavior an object of desire for its own sake. Within a deterministic,
naturalistic view of addiction these aspects of addiction are lost sight of.
An existential dislocation model is a model one might place between a disease model
that perhaps aims too low and a disorder of choice model that perhaps aims too high.
Cook’s theological disorder model (Cook 2006), as a specimen of an existential
dislocation model, tries to ‘normalize’ addiction as something that is inherent in every
human being. By choosing for only a medical view of addiction or, conversely, for only a
moral view of addiction, “we protect ourselves from the implications of admitting the
divisions of self that we experience and yet deny. Instead, we label the addict as either
sinful or sick, projecting on to them the pathology that we disown within ourselves.”
Without denying the medical and moral aspects of addiction, the experience of addiction
then is something that is, as Cook phrases it, “not completely alien to any human being”.
Recognizing that addiction has to do with divisions of the will, with first-order volitions
to continue drug use despite first-order volitions to discontinue, it will lead to the
awareness that only grace (however defined) is able to set people free from their
captivity.
2. Ways out of drug abuse
What has all this to do with the question: rehabilitation instead of punishment? Only
punishment for committed crimes negates what is at stake. An addict is impaired.
Often or almost always existentially dislocated. Rehabilitation must focus on
‘location’ versus ‘dislocation’, on ‘attachment’ instead of ‘detachment, on
‘engagement’ instead of ‘disengagement’. Then what are the ways out of drug abuse?
Rehabilitation. Starts from the premise that addicts can be held accountable but are in
such a situation that they find it hard to make the right, healthy choices. Most of the
addicts that end up in treatment, suffer from comorbidity. But rehabilitation also has to
include addressing the notions of ‘belonging’, of ‘liberation’ and ‘meaning’. They
need to heal from the fragmentation of their identity. As Bruce Alexander states in his
book ‘The globalization of addiction’: “Apparently, there is no pharmacological
antidote to poverty of the spirit” (p.196). Addiction is a problem of modernity where
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conventional wisdom has limited public understanding of addiction to an individual
problem of alcohol and drug use. (Alexander, 206)
So, in my opinion, in the discussion on drugs and what kind of drug policy to pursue,
one cannot escape the broader question of morality, spirituality and the necessity to
ask for the specific philosophies undergirding the different policy positions. However,
this is hardly done. The main line of approach is that of evidence based ideology. The
present day drug discussion, in that regard, seems to be an offshoot of Modernity
where rational (science based) thinking will inevitably lead the way to the correct way
of dealing with the problem and will, finally, result in the appropriate drug policy. This
optimistic, naturalistic approach fails to take into account that more than ‘pure facts’
make up a ‘right’ approach.
A purely medical view of addiction seems to fail in establishing a much needed
holistic approach. Perhaps we have to conclude that present-day central public health
principles of drug policy within a liberal political morality stand in the way of an
integral approach to the addiction problem. However, I uphold that there must be made
room for the element of morality. According to Kinneging (2009) the root of the crisis
of our time is the thinning out of our moral consciousness, our demoralization; that we
have to a large extent forgotten the virtues that morality involves. This applies also to
the way we deal with addiction. By reducing it to a medical condition addiction
appears to have become a controllable phenomenon, but to the exclusion of moral
notions. A remoralization of addiction is necessary. A disorder of choice model
includes moral notions, by emphasizing the possibility for addicts to choose another
life. The addict is responsible for his own life. Without responsibility there is no
individual freedom, at most only adaptation. As Kinneging writes: “If self-constraint
exercised by the conscience is absent, the latter cannot exist. In the words of Edmund
Burke: ‘Without inner control, man is a slave of his passions, his affects. And since
many of those are of an evil nature—they bring disorder, disruption, and destruction—
in the absence of inner control, outer control is required to maintain order and
harmony’”.
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According to some the harm reduction approach has become too individualistic. There
might be some truth in the statement, however, we should take care not to fall into the
other extreme, that the focus should be only on the social. What we need in
considering addiction is an approach that includes both the individual and the social
elements, that is: take into consideration all the subjective elements of addiction and
what addiction means for the social environment. An existential dislocation model of
addiction tries to do just that: it intends to provide an approach to addiction that
includes the biomedical, the psychological, the social as well as the spiritual (i.e.
existential) aspects of addiction. It does not want to restrict itself to the biomedical
aspects nor does it reduce addiction to the social consequences. It purports that the
existential aspects (‘spirituality’) are even the most important ones in considering
addiction. A disease model and even a disorder of choice model stay at the surface of
what constitutes the addiction problem. In the end, the problem of addiction consists of
a deficit of meaning. The existential approach towards addiction serves as the basis for
considering the other (biomedical, social) aspects.
Within a liberal political morality the state must create room where substantive content
can be given to political morality. The state, though it might not opt for one concept of
the good, should take care to establish a kind of substantive minimum with regard to
what constitutes what is good for society. It should not reduce addiction only to public
nuisance or refer it only to the medical institutions, but should encourage civil society
to do its part in tackling the addiction problem. The state should here refrain from an
exclusive neutrality, where it aims at a public arena that is completely free from
religion or any other life ideology – also where it deals with addiction. It should hold
onto an inclusive neutrality where it strives for a public arena where a diversity of
organizations that function on the basis of a religion or life ideology are accepted and
where the latter can function as partner in the execution/implementation of policy. In
this way justice can be done to the deficit of meaning character of addiction.
Meaning refers to the deepest grounds of our human existence. An existential
dislocation model of addiction – and for a Christian, a theological disorder model –
goes beyond the medical, the moralistic and the punitive. In the theological disorder
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model every human being is accepted as being created in the image of God; it deals
with him on the basis of grace and truth. The model acknowledges the human
inclination to evil and does not reduce the addiction problem – or any other problem –
to societal structures. It takes into account that, as Martin Buber says, God has been
eclipsed from the human horizon. And that this has led to the situation that man has
become the measure of all things.
3. Drug treatment in the Netherlands
Dutch addiction care is part of the broader mental health care. This mental health care,
including addiction care, aims at ensuring the availability of high quality, accessible,
affordable and sustainable mental health care. There is a wide variety of services to the
public, ranging from mental health promotion, prevention and primary mental health
care to assisted independent living, sheltered housing, ambulatory specialist mental
health care, clinical psychiatric and forensic institutional care.
Mental health care providers offer counselling, treatment and support to people with
different mental health problems or psychiatric disorders such as anxiety disorders,
depression, addiction, aggression or schizophrenia. The causes and expressions of
these problems vary widely, this calls for many different types of mental healthcare
providers. Some mental health and addiction care providers specialize in a specific
disorder, others provide a variety of services in care pathways, usually offering
prevention, primary mental health care, ambulatory (specialist) care, acute hospital
facilities and long-stay residential care.
The purpose of Dutch drug policy is to prevent drug use and to limit harm to drug
users. In addition, the government takes action to limit the nuisance caused to society
at large. A great deal of information is disseminated about drugs and proper attention
is paid to supervising drug users.
As regards specific forms of addiction care, in the Netherlands this includes help
kicking the habit, designated drug consumption facilities, voluntary or mandatory
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treatment, and inpatient or outpatient care. In the Netherlands, most people with a
drug problem are treated in outpatient addiction care.
Outpatient care involves intervention in acute problems, help kicking the habit,
improving the quality of people’s lives, helping people regulate their consumption and
avoid further damage to their health, reaching out to problem users who do not seek
help themselves (assertive outreach intervention), and preventive measures.
Inpatient care involves crisis care, detoxification programmes, and treatment in clinics,
therapeutic communities or wards in psychiatric hospitals. Inpatient care is more
intensive than outpatient care. It is geared towards preparing people for their return to
society.
Forms of addiction care:
 From harm Reduction to abstinence based facilities
 Ambulantory, semi-residential, residential care (stepped care)
 Social addiction care
 Private clinics
 Christian addiction care
 Self-help groups
Some recent developments:
 Disappearance welfare state
 Participation society
 ‘Ambulatorization’ (reduction of beds)
 Dichotomy in specialized and general mental health care
 Central role for the general practicioner
 Greater use of one’s own social network
4. Concluding remarks
Treatment as part of rehabilitation. Dealing with the core issues. Facilitate integration
in society. Other parts are reintegration, prevention, social support and
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religion/spirituality in the framework of the renewing of moral consciousness. Drug
policy needs to be compassionate policy.
Rehabilitation is in almost all cases the proper thing to do. However, this does not
exclude punishment in some cases. For addiction, as we have seen, does not rule out
accountability. But even when incarceration is demanded, the focus should be as much
as possible on reintegration. For the government has an obligation to facilitate the
possibility of a good life and a good society. It has to contribute to the solving of
societal and social problems. Drug policy as part of government policies in general
cannot be separated from characteristic notions within a democratic society regarding
the summum bonum, the highest good. The possibility or impossibility of drug use and
addiction within a society should be seen within this framework and determines
whether interfering and intervening by the government is appropriate; and, if yes, to
what extent.
In many Western countries the ideas regarding drugs and drug use as well as the
government policy regarding them, have been highly stamped by the cultural
revolution of the sixties. This revolution meant a revaluation of many moral issues,
among which drugs and drug use. Up till that time, desires were subordinate to the
mind. Then, however, the highest good was sought in the satisfaction of the desires,
whatever they might be. The optimum satisfaction of these hedonistic desires would,
according to the 19th century British philosopher, political economist and civil servant
John Stuart Mill’s in his book ‘On Liberty’, result in happiness. Mill also indicated
that that a human being should live in accordance with his own inner unique identity,
in accordance with his so called ‘authenticity’. As far as I can see, hedonism and
authenticity are important factors in understanding what we are dealing with regarding
drugs and drug use.
In the present day liberal morality – with its emphasis on ‘freedom’ – individual
persons are supposed to give their own idiosyncratic meaning to their existence.
Whether a government is allowed to intervene here, is based on the justification
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principle and/or the harm principle. Non-interference by the government (non
paternalism) is often based on the so called neutrality of the government, and the
individual person as the center of all deliberations. However, already Mill in the 19th
century wrote about the possibility of intervention by the government, namely where
the freedom of one person brings harm to the freedom of the other. Where the harm
principle used to be only one of the principles regarding good and evil, today this
principle seems to have been elevated as being the most important principle of
morality. But what exactly constitutes harm is not so easy to define, including harm in
the framework of drug use. Governmental paternalism regarding drug use, i.e. a
restrictive drug policy, can quite well be defended. The dangers connected with drugs
and drug use are such, that restriction of autonomy of the individual has as purpose,
that he is better enabled to make healthy choices and thereby enlarge his future
autonomy and freedom. For freedom is not just freedom ‘from’ but also freedom ‘for’.
Ways out of drug abuse – rehabilitation instead of punishment, ask for accountability,
and making healthy choices possible. Asks for BPSS model. Only focusing on health
without taking into considerations that laws have been broken, and on the other hand
only focusing on punishment without taking into consideration the health aspects
won’t be helpful. Both, rehabilitation and punishment, need to be addressed under the
umbrella of a compassionate drug policy that also takes into account the existential
layer of the addiction problem.
I thank you for your attention.
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