Let’s talk critique- Part deux

I received some interesting questions regarding my post on critique, so I figure it is time, as Paul Harvey says, to tell the rest of the story (while I have the time). Anyone who has studied politics and philosophy knows that for every argument there are counterarguments and alternative theories that come from perceived weaknesses in specific theories. There are such arguments in relation to critique as well. I will generally structure this essay to answer some of the questions I have received, but I won’t be taking them one by one because each question ties into another so composition is more fitting.

Liberation for whom

In the last piece, I noted that critique is a liberatory idea. It rests on what philosopher’s call an a priori. A priori means that certain beliefs are baked into something before it is even experienced or tested. Liberation implies the opposite condition exists automatically – ie domination and oppression are a priori. But who are we talking about when we assume some people are oppressed and some are not?

Well, it actually means a lot of people are dominated by the conceptions of substance use that our society holds. From the individual who has lost control of their substance use and feels ashamed, to the politician who feels they have no other choice but to build another prison. It implies families who suffer the daily torment stuck in the orbit of their destructive loved ones. It means scientists who are bound by specific terms and methods of measurement thought to be the most valid way to define and observe substance use disorders. Clinicians experience this as “best practices” bolstered by ethical standards and ideas of “efficacy.” Doctors are bound to their own tools, largely medicine, and clinics are bound by laws and funding that determine what a clinic can and cannot do. All of this is informed by what we believe to be true about addiction and substance use. We are all dominated by specific ideas related to substance use. These ideas limit us to fields of action, and fields of thought, and these concepts bound our ideas of what is and is not possible when we speak about addiction.

One weakness in liberatory ideas is that they can be non-specific and involve an idea of utopia or a perfect world. There are various ways to respond to this but in essence, it is a specific question – how do we define freedom, and who gets to have it?

In the case of substance use disorders, however, we have to take a step back. We have to recognize that how a politician or a doctor views substance use disorders also limits how others see it, this is related to the way power is entrusted to specific social roles, giving weight and validity to those opinions. Or consider how science has the authority to designate it as a disease or quantify how much is bad or indicative of illness. These are not unrelated to how the individual using substances sees themselves, nor is it unrelated to how their family views them. In fact, all of these are tied to specific socially constructed matrices of assumptions we make about substance use as a whole. They inform one another and are in constant dialogue. And wires get crossed all the time.

For example, a parent may plead with a family physician to put their child on medication (having read about how medication reduces death) because they do not want to lose their child to overdose. However, the child themselves may not want it, and may not even see their substance use as a problem. Or consider the spouse who wants their partner to quit drinking. They don’t want their partner to moderate, or try to control it, they want them to stop. While their partner might be willing to try medication, therapy, and moderation. Or consider the old timer in N.A. approached by a young person who says they think medication might be a better option for them. Or consider the methadone client sitting in the parking lot after driving an hour to the clinic before work, thinking to themselves that there has a better way to get free of their addiction.

Next, we have to consider the system in which we treat substance use. A gentrified, class-based system, that is more reliant on whether one can pay for services than whether one needs those services or not. The poor get one type of care, and the more fortunate get access to another type of care. Those who are already facing oppression outside of their substance use face imprisonment, not treatment. The only truly accessible and ubiquitous institutions that will serve everyone are aimed at specific outcomes (abstinence), which may or may not be what individuals need or want. We cannot pretend that any area of the field is absolutely just, equitable, or fair. Nor can we pretend that things like insurance, profit, wages, housing, employment, and health systems don’t play a serious role in whether one recovers or not. Who gets care, and who gets to go to jail is a political, not a clinical reality. Who gets one type of treatment over another, is a matter of status, not a matter of necessity. When we consider how we frame substance use disorders in society, is it any wonder that we allow such obvious systemic savagery to literally kill and deny some while elevating and compassionately treating the privileged? In this way, we accept something so gravely unjust and we become bound and held captive by its cruel mechanisms and unjust outcomes.

And yet, simultaneously we also understand that there is no perfect system that can respond to all of this. This is where the main weakness of critical lenses becomes apparent. And most of us walk away at this point and say, “Well it is a cool idea but it isn’t pragmatic. No system or set of ideas can be free from all of these delimiting and unfair facts.” We believe that perfection of concepts and ensuing systems must be achieved for it to be pragmatic.

The critical mistake

In many ways at this juncture, we do the work of oppression. That’s right, we become operative agents who promote injustice and oppression precisely because we write off the Utopia that we feel is unrealistic. The absent but implicit overture is that in doing so we further entrench the way things are by assuming they can never change. Or by believing that the end goal is an unreachable utopia, we then have no choice but to accept the status quo and at best, incremental change. This essentially throws out the entire critical project, at the expense of those who are most negatively affected because we “just don’t see how alternatives would be realistic.” This is a trap.

Circumventions

We can start from a different place altogether. Already in my last post, I offered a rubric for evaluating what we do and how we think about substance use disorders in society. This rubric has us rely on critical values, rather than systemically offered cues, to make judgments about how we are responding to substance use in society.

Let me offer an example we are probably all familiar with. An insurance company agrees to pay for four days of care in an inpatient facility for your client. Clinically, you surmise they will need a minimum of 90 days, given their severity, and the outcome goal you and the client agreed upon, which you will periodically reevaluate and adjust according to progress made by the client. It is clear you have to fight to justify every day that this client requires care. You are prepared for this because this is how the system works. So you produce the necessary clinical documentation and rationalizations that meet or exceed what the system requires in order to continue care. Most of us go exactly this far. And while we have gripes about this system, it has never stopped us from participating in it, nor has it ever stopped us from producing what the system requires of us in order to function.

Let’s evaluate this in terms of critical values. Is it fair? No, in fact, it seems really unfair. Is it just? Fighting for my client is just, having to fight profit motive so I can care for people to the best of my clinical capacity is not. Does this promote equality in society? No, it feeds a machine that thrives on inequality. My client deserves care, they will get it because they can participate in an unfair system, others will not, however, even though they deserve it.

Now comes the hard part

If we take seriously and believe in critical values (not everyone does), what should our practices be in light of the above example? Having used a critical rubric we see there are a lot of shortcomings that violate the values we say that we hold. We are faced with a moral and political dilemma. If we believe in these values we will act in ways that promote them. If we do not believe in them, we should be honest with ourselves. How do we know which one is us? Well….(drumroll)…

You know whether or not you value fairness, justice, and equality by what you do and what actions you take.

Do you organize resistance? Form a union among treatment providers with enough power to say, “No.” Do you develop underground networks of care for people who can’t pay? Do you push the system you work in to expand options, infrastructures like job placement, and housing? Do you work “off the books”? Do you testify before your state legislature, write your congressperson, rally, protest, or get arrested in front of Blu Cross Blu Shield HQ? Do you keep secret files and information about this industry, about the people left out, and about the practices that are used to exploit families and clients? Do you expose bad actors? Faulty practices? Inhumane forms of care? Do you insist your employers take a stand, and clearly state their goals? Do you bring down false advertising, and contact better business bureaus? Do you collect accounts from people who access the system? Do you talk to prisoners? Do you get fired, do people threaten to file complaints, have your license revoked, or do you insist at every turn that complete and full care of the individual is the only ethical practice there is, and you won’t participate in anything less, do you get thousands of other clinicians to agree with you? Do you walk away entirely unable to work within a system of injustice?

It is okay if you do not. But, then you need to re-evaluate what you believe about the values you do hold. Part of the problem in this field (and our nation as a whole), is that we believe that wanting to hold values is the same as holding those values. It is not. Critical values are not performative. They are not spoken, they are enacted. They are not signaled, they are put into motion. Critical values are not Tweets or complaints. They are direct confrontations with things in the world that go against critical values. Critical values mean that one actively and constantly acts in resistance to injustice and inequity.

Hopefully, this illustrates the scope of what critique actually means.

Most of us will read this and say that we work really hard. That we have no time for this, or that we do what we can when we can. Don’t beat yourself up if you are not leading a revolution. We are all taxed by the system. And the system stays in place because of the way it wears down resistance. The way we construct addiction in our society positions the clinician and the sufferer, the doctor, and the scientist- all in ways that avoid confrontation with the ruling order. That is what power does – it ensures its own continuation. Often we want to help, we want change, and we want to help people live life to the fullest, with adequate care and support. Recognizing your own fatigue when confronted by what critical practice might look like is a great place to begin to understand how critique broadens our consciousness in our everyday lives in the field. We know the problems that face the field. We’ve always known them. But we have spent far more energy adapting to injustice than we have spent fighting it. And, if nothing else, maybe that is a good place to start if a critical project is what we want.

With that said, we can see that critique is not for everyone. After all, people have lives, families to support, mortgages to pay, and interests that have nothing to do with the field. Do we not also deserve to live our own lives?

That brings us to the final problem. There is a direct correlation between our engagement in change and the deprivation of life, health, and liberty we allow to continue and be inflicted on others. Now, no one can tell you what that may mean to you, whether it drives a sense of urgency or obligation. Whether one is willing to take up risks for themselves in the fight for others is not, and cannot be generalized in America. But it is a question. A private question that I at least feel we should each attempt to ask ourselves. Rather than writing all of this off as Utopia, are we at least willing to privately confront ourselves? The shortcoming of critique is not necessarily with the theory itself, I find. In many ways, the fault exists within the self. Utopian or not, we cannot make such judgments until we are willing to act.