I’ve been working on a paper on recovery that is sort of a philosophical treatise on what it means to be critical regarding science, practices, and system design in relation to substance use disorders, care, and treatment. As Jason had noted in one of his earlier posts, there is plenty of criticism to go around. There are so many layers to all of this, and so much room for improvement, and growth for all of us. His post reminded me that there are several meanings tied in with the notion of critique that I feel we might benefit from a brief review of what a critical gaze of the field entails.
Sensitivity to Power
In my opinion, power is one of the most overlooked and misused aspects of critique, particularly in this field. As clinicians however we received some form of training in the idea of differential power between the client and the practitioner. This is perhaps the power differential we are all the most familiar with. It serves as a good model we can all relate to in that we are acutely aware that the relationship between ourselves and the client is not on equal terms by default. Part of our jobs in professional practice is to understand this, and mitigate the differential, while never giving up our role. We do this by active listening, involving the client in care planning, and clearly defining specific roles, goals, and outcomes we agree upon with the client. We seek to co-construct our work with the client. We tend to think of power over the client as something that should be handled with deep care, and in some ways, we tend to see power over a client as sort of an ugly way of thinking about our role. In doing so, however, in downplaying our own awareness of power, we forget that power is not personal. It is our role, not our own self through which power is expressed. Power arranges the room, therapist to client, not I to you the individual person. Outside of the therapy room, power shifts to other arrangements, for example, a business owner to a business client, as the person pays their session bill and leaves in the case of private practice. Outside of our office, the client and the therapist are merely citizens to one another. Roles and context follow the orderings of power and the design of society.
Understanding that power is not an object, nor a “thing” that one has or can grasp is important. Power is expressed through relational arrangements, often through larger systems and frameworks like professional education, credentialing, economic infrastructure, scientific discourses, and specific practices. This is as true for the person with a substance use disorder as it is for the person holding a professional license. Their identity as a sufferer, as is yours as a therapist, are both socially constructed outside of the self. This means that at some point the social articulations of the sufferer’s experience were defined as X and a person with your skills to promote healing is defined as Y. Hence, X needs Y because Y is thought to be (i.e., defined by social history) the way to ameliorate this other thing social history has constructed as X. Pathology is a discourse, as is health.
There are whole bodies of knowledge that are fashioned to define, justify, theorize, and shape pathology as a “thing” or object that exists in the world, as something that is embodied by people, and whose source, causes, origins, and manifestations are identified and itemized. These are the conditions of X. X is a product of a vast system of historical forms of knowledge and statements made about some part of X, and taken together, all of the statements about X are considered to be the “truth about X.” From this truth about X, we have developed Y, in similar ways, and in response to X. The discourses that constitute X are in constant dialogue with the discourses that constitute Y.
Whether we are talking about pathology as X, therapeutic practice as Y, or any other socially constructed system, we must recognize first and foremost that power is required in order to give X or Y the validity of truth. The authority of science, metrics, texts, experimental methods, and rigid observation is thought to be the means by which we can say with certainty that X is indeed a thing in the world and that Y is the best way to address it. This is all well and good until we really consider the role of power. Power is political. Power is not a scientific reality, power is the arrangement of reality in and around specific human interests. Thus the very nature of truth, is a political, rather than scientific occurrence.
Why do we construct one thing as pathology and another as non-pathology? Is it really about health?
Surely centering oneself and one’s identity through an activity of buying and selling specific numbers on a computer screen as a 60-hour-a-week profession is not healthy. Surely being put in a small concrete cage for years of one’s life is not healthy. Surely living a life that is defined by the constant struggle to sell one’s energy and secure the medium of exchange (money) necessary to support one’s own biological function is not necessarily healthy. So whether I am a Wall Street banker, a prisoner, or an average consumer, my life is not centered on health. Health is a secondary concern at best. Success, punishment, and market participation all take precedence over health for each of these examples. So is it really about health? When we seek to restore someone who has been deemed pathological, what are we seeking to restore them to? And are our efforts at restoration really about placing the person in a position to be healthy?
Furthermore, who benefits (politically) when a portion of our population is considered to be pathological because they engage in the autocratic manipulation of their own biochemistry? When they interact with unregulated illicit markets that are international networks? Who profits? Who gets to be in control? Whose authority becomes the source of truth? Who has a job because of the way we define substance use, and who is considered unemployable? Who gets to survive, and who dies? Whose life gets placed in suspension? Why might we view such a person and their behavior negatively? Who told us this was “bad”? Where did we learn this, and why do we accept it as unassailable truth?
Complicating the Picture
Now that we have kicked the walls out and opened up some intellectual space, we see that we can do this with any form of knowledge that defines various aspects of reality. I mean, are the suburbs really ideal living? Why do we accept sitting in traffic as if it is normal for individual humans to sit in steel boxes for hours a week? Are we really meant to be paired in monogamous relations for decades? Does a dollar really have any value? We can do this to an infinite degree. But what is important about this skill is that it allows us the necessary space for critique to actually enter into the discussion. By complicating the ideas we take for granted, by questioning forms of truth we assume to be real, we allow ourselves the possibility of seeing the world in a new way.
In my perusals of social media, I see criticism often without this capacity. For example, “safe supply is the only answer to the opioid crisis.”…”One size fits all treatment doesn’t work”…. “Abstinence isn’t for everyone”… “Drug users are stigmatized”…”The war on drugs is racist.” We have all heard these statements and arguments. There are certain statements and ideas which precede these comments, and there are specific implications to which these statements are aimed. However, these are not critiques. The way I view these statements are that they are similar to loose tiles in a large mosaic. They are points of instability within the larger picture of how we view, define, rationalize, and treat the use of substances in our western society. They promote questions, raise interesting and necessary points for concern, and they are valuable. They are also very preliminary in the process of critique.
So, what is critique? Or rather, how should we critique this field, this mosaic in which we all live and breathe? Well, by definition critique both identifies power and the expressions of power, while also giving rise to the notion of liberation. You see, critique is a liberatory effort. It seeks to free the subject from the ensnarements of power that oppress or otherwise delimit the subject. This subject can be a person, such as a client, but it can also be an idea. There are lots of ideas that never see the light of day precisely because of the way power arranges reality in opposition to those ideas. This is the ruling order of reality, and it is a space defined by forms of power. “The reason we have therapists is that we have a need for them in society,” yet, turn this on its head and things get weird. “The reason we have pathological substance users is that we have a need for them in society.” You see how your mind resists one of these statements but accepts the other. One seems valid, and the other seems like a stretch or falsehood, almost conspiratorial. If someone suggests our society requires a certain amount of people to live in poverty, or in prison, we struggle to get away from that idea. But if we say that doctors, politicians, and bankers are needed for society to function, we hop right on board that train. Why?
Part of the issue is that we misunderstand how power functions in our society and even through our own ideas and activities. The other reason is that we have a moral dimension we associate with power. “Police are generally good because they fight crime.” We never really say, “crime is needed to challenge the power of law.” And we almost certainly never consider that crime is invented to create jobs. Yet, crime is the singular rationale for billions of jobs worldwide. They exist because of crime. Yet crime too is a creation of our own constructs, generally defined by those upon whom the crime has a negative impact. You see where this leads. On the one hand, we have an idea that is dominant, on the other we have an idea that is subordinate. Inside of those ideas we place people, like the police, who are “good” and the criminal, who is “bad.” These associations in turn ripple out into society, politics, economics, and social institutions until they become what feels like the natural order of things.
Now, onto liberation
Who is kept captive by the normal order of things? Who is excluded? Why? What are the moral assumptions that underly that exclusion? If we take seriously these ideas which challenge the status quo, these loose tiles in the mosaic of substance use disorders, treatment, and care, then we cannot escape the necessity of this question. If we legalize a substance, who is set free? Who or what is now bound and forced to be accepted in this new reality? If legal has nothing to with health or wellness per se, then what is our role? What do we, then, promote? There are always individuals who will be lifted up, and others who are denied when we rearrange systems and ideas. Health, happiness, and resources will be gained or lost to specific individuals. The “trick” or the real test is how we respond to the dichotomies that develop when power shifts into new arrangements. This is the point of critique. It is more than criticism. It is about finding and defining practices, systems of knowledge, and expressions of truth that maximize liberation for everyone. It is not about saying one thing is good, and the other is bad. It doesn’t matter what rubric is marshaled to justify the goodness or badness of something. It is about abandoning the need to make something bad so we can treat it in one way, and the need to make something good, so we can treat it in another. The Key? Principles. Or rather, justifying not by diffuse constructs like “health,” “legality,” or “pathology” but through universal principles that are specifically informed by human liberation.
Whoa there… sounds pretty eccentric
Let’s test it out then. Instead of asking if some system of care is “effective” let us ask instead, is it fair? (wrench, meet the works). Right away we see the difference, we see the threat to the status quo such a question poses. Instead of “effective” let us ask if some specific treatment promotes equality. Instead of determining if a treatment is cost-effective, let us instead ask if it is just. Instead of defining our roles as clinicians who promote health and reduce pathology, let us instead define ourselves as people interested in equity. Equity that is not defined as materialism or identity (though these may be part of it) – but as life, as promoting the ability to live, and the provision of that ability to as many as possible. Instead of just questioning treatment modalities, let’s ask these same questions of the law. Is it fair? Does it promote equity? Is it just? Or let’s apply this to the systems we work in. Is our state mental health care system fair? Does it promote equality among all citizens? Does it serve human justice? In short, do the ways we think, act, speak, study, and operate within this giant mosaic really set people free? Or do we ensnare, and limit others with what we do? Are we agents that represent critical values? Do we represent fair systems? Do we abide by laws and professional ethics that are actually shaped through justice?
I think, when given these ideas, we find there is far more work to do. When given these ideas we transcend the argumentative layer between various ideas about how we should see and respond to substance use disorders. And, most importantly, when given these ideas we are confronted, inescapably, by difficult questions that in a lifetime can only be chipped away at. Yet, with such a northern star guiding our practices and ideas, we can at least be assured that we are perpetually striving toward some future reality that pays homage to the human spirit, and life itself. There is no more radical sense of health than the ability to live as well as one can, individually and in cooperation with humanity. And most importantly, we now have an essential rubric by which to judge our own ideas and actions through a critical lens. We will never achieve the ideal, but that is not really what this is about- it is about shifting the elements of existing reality into new and better forms that over time, and with effort, bring into reach just, fair, and equitable ways of practice by promoting systems that are true to those principles. Whether we are talking about treatment, or anything else. That is the nature of critique.