Stigma and community

I read this Ta-Nehisi Coates post yesterday on domestic violence, responsibility, individual agency, community, shame, isolation and empowerment. It’s really stuck with me. Very heavy, heady stuff in a very short post.

It got me thinking about some of the mechanisms of addiction and stigma, and the healing mechanisms of the recovering community. He points out the empowering aspects of a community of oppressed people and the responsibility this community confers upon its members.

Further along these lines, Bill White has a new paper on stigma, addiction and methadone. It poses some interesting challenges to the recovering community. How do we reduce the isolation of MMT patients trying to recover? What does recovery mean in the context of MMT? “Responsibility” in the paragraph above could be interchanged with standards. One of the healing mechanisms of the recovering community is imposing standards expectations (responsibility) on its members. Would bringing MMT patients into the community erode this? (There were similar fears with psychotropics.) Does this open a door for benzos and other meds? Clearly, these standards protect the recovering community, but they also constitute a barrier.

The conundrum here is that suspicion about MMT has been pretty persistent for good reason. The paper does a good job addressing the failure of MMT in facilitating recovery. Many members of the recovering community question whether its possible for large numbers of people to achieve and maintain recovery while on methadone–if methadone is such a helpful tool and isn’t a barrier to recovery, then why, with the wide distribution of methadone clinics, haven’t these people been able to form their own thriving tribe within the recovering community?

It would seem that the best way to test this (the degree to which intra-group stigmatization constitutes a barrier to recovery) would be to have these folks be welcomed into the arms of the recovering community and see how they do. But, how do we get there when this suspicion persists? And, how do we respect the role of these standards in the recovering community when considering the needs of MMT patients?

This challenge is not going away.

UPDATE: Maybe expectations would have been a better choice of words than standards?

13 thoughts on “Stigma and community

  1. I hope I express myself so that I'm understood with this comment.As a layperson (and mother) I read a lot of blogs..people in recovery with AA, NA, or their own personal formula. I also read blogs of addicts still using, and a fair number of them are using (abusing) methadone. They write about selling it, or using it in conjunction with other drugs. None of them are in a program or treatment as part of their daily dose. They pick up their methadone and generally complain about how they are treated or about having to make the trip to the clinic. I have read a handful of people who are using methadone as a real tool to recovery. These people obviously benefit, and society benefits, but frankly they seem to be the minority. Or maybe they just don't come forward because of the stigma.Trying to be objective here…the average joe will never accept it as real treatment, until the people using it demonstrate real recovery.

  2. You're describing my experience with methadone too. I respect Bill White a lot and he's told me that Michigan's clinics are not representative of what's occurring in the rest of the country–that the coasts are better.

  3. Methadone is targeted at the poor. There are few if any clinics in affluent neighborhoods. People who run the clinics commute from the suburbs take their money and go home. They kick you out if you get behind on payments and let you drop dirty for other drugs as long as you pay. People in the parking lot sell klonopin and xanax as well as their takehome doses of methadone.People are forced to line up like slaves out front or around back at five am. The place is more fortified than fort knox. Methadone overdoses are not uncommon. Counselling at clinics is a joke, "any cravings, should we up your dose?" is not an effective counseling intervention. HMM, why would anyone be suspicious? It is horribly unfortunate that people who really do need help are relegated to these places. The stigma that is attached to methadone patients is largely a byproduct of public policy surrounding methadone and systemic failings within the methadone "treatment" community. Unfortunately the onus is on the successful methadone patients to work to change the system (if there are any). There need to be consumer run methadone co ops that provide services to the consumer that are actually needed.

  4. There is no other illness whose treatment requires the degradation that methadone providers put their clients through. It would not be stood for. It really is outrageous and immoral. It seems to me that if physicians really thought that this was a viable treatment they would do something about it. It also seems that if these providers actually cared they would provide a very different experience.

  5. I'm interested in the word 'standards' or 'expectations' and what you mean by it Jason. I have my own ideas about that and if we are confluent, then it is quite hard to know how to move forward.There are so many strands to this which makes it difficult. An emotional or visceral response in me needs to be acknowledged before I can attempt to be objective.I've worked for years with MMT clients/patients and I don't see recovery emerging on the whole. That may be systematic. Some would argue that we have no right to define recovery for another, yet we need some sort of working definition if we are to be a community.Take a look at:http://findings.org.uk/count/downloads/download.php?file=Mattick_RP_2.txt where you'll find a Cochrane review of methadone vs other interventions in the context of randomised trials. Yet it misses the point for me on so many levels.I do wonder if MMT clients were invited and welcomed in the recovery community, that they might leave addiction communities and naturally start to fulfil some of the expectations of the recovery community, through being supported by it. Lots of hurdles and I'm not sure everyone wants to jump that high.

  6. @Peapod I guess I was referring to Ta-Nehisi's post and the role of community in individual agency. Being part of a community provides a bar with which we evaluate ourselves and others evaluate us. In healthy communities this encourages us to push ourselves and each other to achieve our potential.

  7. Do many methadone clients want to be part of the recovering community? If not this discussion is not very practical. Opiate replacement,or the idea of a head full of opiates, can indeed instigate a visceral response and can be threatening to some people who have achieved abstinence.Just as abstinence based recovery can feel threatening to MMT patients. There are certain norms and values in the recovering community, and and abstinence is generally one of the most important. There are people who are abstinent who do not make positive lifestyle changes and have a hard time in the community, they usually either change or leave. There are also people on maintenance who do start to make changes and are reached out to by the community. There are many,many people for whom maintenance does not work,(if it did no one would be abstinent). These people value their abstinence more than anything else in the world. If they forget how important their abstinence is they tend to lose it. I imagine that it is very hard to sit in a room with people who value their abstinence this much when you are on maintenance.

  8. @anonymous Great points. One things that's interesting is that the recovering community generally tends to warmly welcome people that are under the influence with the premise that they have a desire to stop using. So it's not the drug. I'm thinking the threat is more around the meaning of recovery–do maintenance patients change the definition of recovery in a way that threatens the recovery of individuals and the group? Being drug-free has always been a core element of recovery–would tinkering with that eat at the glue that binds the recovering community?I keep coming back to the need for MMT patients to form their own community of recovery, much as NA did. Once it's established and there are large numbers of visible winners, there might be more potential for crossover and integration, or it might not be necessary.

  9. Is the recovering community defined by people in 12 step programs or can people who have stopped alcohol and drugs in a harmful way and have moved om with their lives be considered as in recovery? There seems to be a tendency in the 12 step community to devalue other recovery styles – e.g. labelling people who do not go to meetings as "dry drunks" and excluding people on psych meds or prescribed medications such as methadone. People can walk the walk in recovery without necessarily talking the same talk as 12 step people.

  10. @anonymous Good point. When talking about communities of recovery, three groups come to mind: 12 step recovery, faith-based recovery groups, and secular recovery groups (almost nonexistant in my region). 12 step recovery is definitely the largest and most widely available.12 step groups have often defined recovery too narrowly even though AA step literature is explicit that AA has ONE path to recovery. Fortunately the groups that approach psych meds in the way you describe are few and far between.

  11. Recovering implies lifestyle change. Recovering community implies community of people who are making lifestyle change.People talk about "tribes", is not the 12 step recovery community but one of these? People in the 12 step community are going to "talk the talk" of the 12 step community. Should that change to accommodate others? Obviously there are many paths to recovery.How many of them involve community? Correct me if I'm wrong but I am not sure that 12 step groups have tried to define recovery for others, just for those in their tribe.

  12. As always, thanks for you post. the comments are concise and provoking. As one of those dry drunks who was not 'working the program for nearly 13 of my 17 years of sobriety, well, I did feel the isolation of not being part of the whole group. Although when I spoke of my 'situation' I had a lot of non-judgemental recovering addicts come to me to offer support. I still don't do everything I a 'supposed' to do, but I seem to be happy, healthy and wise. Well, ha ha…most of the time.

  13. I kicked a bad habit involving a lot of drugs a lot of years ago, at age 19. Addicts weren't welcome in AA then and NA was scarse. My son is sober in AA for 18 months now. His sponsor thinks I'm a "bad influence" because I don't go to AA, despite the fact that I've been clean longer than he's been on this earth – and have long since moved on to a responsible life. Go figure.

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