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Abstract
The eye only sees what the mind is prepared to comprehendHenri Bergson
The relatively new labels, “peer workers,” “peer health counselors,” etc., are explored in terms of a selected number of their implications—few, if any, of which have been or are positive for this targeted population.
THE AUTHORS
Stan Einstein, Ph.D., clinical and social psychologist; student; academician; researcher; journalist (newspaper and radio); editor/author (28 books); journal editor-founder Substance Use and Misuse; Drug Forum; Social Pharmacology; Violence, Aggression and Terrorism; and Altered States of Consciousness; consultant; lecturer; conference and training program organizer; volunteer; awards (Pace Setter award, NIDA; Mayor of Jerusalem Outstanding Volunteer Award). Area of interest: the parameters of failure.
Notes
4 A singular “identity” can be misleading, including as it does one's inner-intimate “real self”, a range of external “social selves”, age, gender, ethnic, religious, socio-economic, membership identities, political, community, etc., which can be temporary as well as permanent, self-determined as well as determined by others.
5 Goffman (Citation1968) noted that a stigma is “an attribute that is deeply discrediting,” which occurs when an individual is disqualified from social acceptance due to a specific real or attributed attribute or flaw.
6 The following words, ascribed to an important Rabbinic source, the Kotzker Rebbe, are an important caveat in this article's trek: “If I am I because I am I, and you are you, because you are you, then I am I and you are you. However, if I am I because you are you, and you are you because I am I, then I am not I, and you are not you” (Heschel, Citation1973, p. 144).
7 The reader is referred to a recent study in which the judgments of 516 clinicians attending two mental health conferences were assessed to determine whether different judgments might be evoked by the terms “substance abuser” and “having a substance use disorder” in relation to behavioral self-regulation, social threat, and treatment versus punishment using vignettes. The two commonly used terms produced systematically different reactions. These professional treaters of others, considering the vignettes that compared a drug user, noted as having a “substance use disorder,” with those in the “substance abuser” condition, judged that the “substance abuser” was personally responsible and that punitive action was necessary. A stigma was associated with the term “substance abuser” even among highly educated mental health workers. This study was designed to explore barriers to treatment seeking and its outcomes. This article asks you, the reader, to consider the newly created labels of “peer workers,” etc., as potential institutionalized “normed” barriers to the effective and sustained delivery of care and services by active substance users (Kelly & Westerhoff, Citation2010).
8 Consider that “peer workers” appears to be just a label; a job category which raises the complex issue of what are the necessary conditions for it to become and/or be a stereotype, potentially stigmatized, which limits individuality? “Peer workers” is a consensualized code, in the contemporary professional literature, for an ongoing life style-behavior choice which one's professional title and status-–physician, psychologist, social worker, occupational therapist, nurse, etc. as well as a range of para-professionals—do not connote.
9 As I write this article, an 8.9 Richter scale earthquake has hit Japan with tsunami waves traveling at the speed of 747 jumbo jets in a country well prepared for disasters of Nature but only given 60 seconds of warning.
10 All diagnoses are labels, nosological systems; all labels are not diagnoses. Diagnosers, whatever their discipline and treatment ideologies, should not be labeling.
11 The first “drug court” began in Miami, Florida, in 1989 in direct response to the backlog of court cases involving charges of drug possession and drug trafficking. It has since become an option for adjudicated, willing substance users to be moved from the criminal justice system to a court-stimulated, abstinence-oriented treatment system in which a traditional medical hierarchy is replaced with a judicial hierarchy. This type of specialized court has spread throughout the US and in other countries as well. The term is misleading. Drugs are not “courted!” This is either a “drug user court” or a “drug user treatment enabling court” which can and does make an important contribution to society (Harrison, Scarpitti, Amir, & Einstein Citation2002).
12 The reader is referred to Hill and Cheadle (Citation1996) as well as to Craughwell (Citation2006), who noted that the Catholic calendar was and is full of notorious men and women who turned their lives around and became saints. Neither “peer-sinners” nor “peer-saints.” Just human beings who sinned as only humans can and do and in all likelihood will continue to do so.
13 Synanon, initially created by a former AA participant, Chuck Dederich, in 1958, as a mutual-help-based, hierarchical structured drug user rehabilitation program and a forerunner of therapeutic communities, later becoming an alternative community. It used group truth-telling sessions that came to be known as the “Synanon game” as an institutionalized process for self-examination. The “game” combined group confrontation and encounter-–attack therapy-–often humiliating the “target,” sitting in the “hot seat” in the center of the circle, for his/her own good and needed pro-social development.
14 In the Nazi concentration camp “tag system”, for example:
Black was for asocial, a catch-all term for vagrants, bums, prostitutes, hobos, alcoholics who were living on the streets, or anyone who did not have a permanent address. There were no special tags for drug addicts. A dramatic juxtapositioning existed between the Nazis’ ideology which: (1) preached abstinence in the name of promoting national health, (2) supplied their soldiers with drugs and alcohol, and (3) criminalized civilian alcoholics. Pervitin, an amphetamine introduced in 1938 by Temmler, a German pharmaceutical company, was considered to be a “wonder drug” which could help the Wehrmacht win the war. It was the drug of choice, but many soldiers became addicted to morphine and alcohol. It has been posited that the Nazi leadership was more lenient with those who became drug-addicted as a result of the war than with alcoholics, because the Wehrmacht may have been concerned that it could be sued for damages, being that it was in fact responsible for dispensing the drugs in the first place (Ulrich, Citation2005). Reichsmarschall Herman Göring was addicted to morphine (Frischauer & Jackson, Citation1951).
The “work-shy,” or those who were arrested because they refused to work, wore a black badge. (In some of the camps, the “work-shy” wore a white badge.)
Red was for Communists, Social Democrats, anarchists, and other “enemies of the state.”
Green was for German criminals.
Blue was for foreign forced laborers.
Brown was for gypsies.
Pink was for homosexuals.
Purple was for Jehovah's Witnesses.
15 The reader is asked to consider that a useable diagnosis, which is the outcome of collecting relevant materials to make a judgment and decision, which may or may not actually be needed by the diagnosed and/or the diagnoser, should enable one to have some sense of etiology, process, and prognosis. In our modern, science-driven world, a medical diagnosis should also be an informed decision that is evidence based. The reality is that the range of US and European secular diagnostic bibles are publications of consensualized judgments by trained human beings who, as such, are necessarily imperfect, as all of us are. Psychiatric diagnoses are not evidence based, which perhaps, etiologically, is an outcome of Adam and Eve's lack of compliance. Perhaps this Biblical tale was the first description of a non-clinical trial testing, that what would happen in the future when one did not follow orders in the here and now. A fourth and increasing function of a medical diagnosis, particularly in advanced countries which represent the “haves” … notwithstanding their many “have-nots” among them … is that the physician would not get paid if there is no diagnosis. “Substance use disorder” can and does pay the bills and keeps some people off the welfare rolls (becoming a welfare recipient)/roles (a self- as well as societal-created identity), while making it possible for others to join in.
16 This thesis’ analysis of individual behavior is that individuals will not, voluntarily, take actions which they expect will make them worse off. Such an analysis leaves it to the individual to judge when s/he is better off and when s/he is worse off. A person's preferences and tastes can be selfish or altruistic, farsighted or myopic, harmful to self and/or others or not. The whole notion of better or worse off, in this thesis, is strictly subjective and dynamic and not the provenance of stakeholders … whatever their sources of influence, types, and levels of knowledge and experience, position, and status. We, as people, given our imperfections, “weigh up” the marginal costs and benefits of our actions. This thesis challenges the moral, criminal, and medical models of substance use and users, which are based upon a posited ongoing existing “impairment.”
17 Complicated and complex are often confused and used interchangeably. They are quite different in their essence. We need to be sensitive to their distinctions particularly when we “medicalize” and “pathologize” people, their behavior and lifestyles. A complicated system is a combination of many units, each maintaining its identity along the way and outside of the system. Consider a screw in a 747 Jumbo jet. If you modify the screw a little bit, the system would not work; complications will occur. In a complex system, each component changes, over time, losing its identity outside of the system: caterpillar ↔ cocoon ↔ butterfly ↔ egg.
18 The reader interested in exploring the dimensions of answers and their implications to why are referred to Charles Tilly's book Why (2006) as well as to Seife's (Citation2010) concept of proofiness … the art of using bogus mathematical arguments to prove something that you know in your heart is true—even when, in fact, it is not.
19 The cyberneticist Heinz Von Foerster posited that there are two types of questions: legitimate questions and illegitimate questions. The former are those for which the answer is not known yet or is unknowable given our state of knowledge, resources, etc. An illegitimate question is one for which the answer is known (Von Foerster, Mora & Amiot, Citation1960). The reader is referred to Pablo Neruda's (2001) The Book of Questions for a poetic exploration of legitimate questions.
20 This article in this Special Issue of Substance Use and Misuse and its range are references and resources for creating the needed changes. The editors have rightly suggested that I remind you, the reader, that in the US, the inner-cities have few employment prospects. One of the goals of a peer worker's social role is to be flexible and not sharply demarcated so that it can fit with the lives and opportunities of impoverished drug users. Peer education is commonly used for non-drug users’ medical care. One can easily relate this role, for example, to that of China's barefoot doctors (
), who were farmers who received minimal basic medical and paramedical training and worked in rural villages in the People's Republic of China. Their purpose, mandated by the government, was to bring health care to rural areas where urban-trained doctors would not settle. These deliverers of care and services had not been and were not stigmatized or marginalized, as was the experiences of peer workers. Employment and/or the opportunity to volunteer is a necessary dimension of a person's well-being and quality of life whatever the individual's chemical appetites or abstemious lifestyle.
21 A reminder that BEING a drug user can be a full-time, part-time, or very partial-time work, just as living and surviving is for all of US mortals.
22 A floating white triangle, which does not exist in the Kanzia Triangle, is seen. People, US, and our brains, manifest a need to see familiar simple objects and a tendency to create a “whole” image from individual elements. In order to make sense of the worlds in which we live, function, and adapt, it is necessary to organize incoming sensations into information and knowledge which is meaningful and, at times, allows us to achieve understanding and wisdom. In the duck–rabbit illusion, the figure and ground are reversible as what one perceives, as a whole, switches back and forth from being a duck and then being a rabbit. The “substance use disordered” are stakeholder-constructed illusions that do not move back and forth even when they have diffefrent names, narratives, or personae.
23 These four categories-codes are often found in contemporary peer-reviewed literature.
24 Quality of life (QOL) measures, which can also be considered as indices for well-being, initially developed in the US during the 1970s by Flanagan (Citation1978), have become an important part of health outcome appraisal, particularly for populations with chronic diseases; these measures are used to provide a meaningful way to determine the impact of health care when cure, however defined, is not possible. Hundreds of instruments have been developed to measure QOL (Berzon, Donnelly, Simpson, Simeon, & Tilson, 1995). The concept of QoL is used to evaluate the general well-being of individuals and societies. The World Health Organization initiated its Quality of Life collaborative project in a number of centers, globally, in 1991. The aim “was to develop an international cross-culturally comparable quality of life assessment instrument,” the WHOQOL, which would evaluate “the individual's perceptions in the context of their culture and value systems, and their personal goals, standards and concerns” (http://www.who.int/substance_abuse/research_tools/whoqolbref/en/).
25 Consider that treatment alliance/engagement, as a concept and process, has been acknowledged as being an important dimension for effective treatment to be initiated as well as maintained. There are scales which measure it. Has anyone considered using the same scales with the range of “therapists” treating substance use disorders-–whatever their ideological commitment, techniques used, experience, and expertise-–to determine if THEY were engaged in the treatment process?
26 The editors rightly reminded me that many chronic long-term drug users are unable to engage in traditional employment, especially those without education, cognitive impairment from drug overdoses, and malnutrition and a range of other disabling diseases. It is important to provide them, as well as non-users in the same situations, with other viable and meaningful social roles. At issue is what are the necessary conditions to do so in a humanizing, non-marginalizing manner.
27 The interested reader is referred to: www.erowid.org and their list of “famous people and their drug use,” which can be interpreted as suggesting that not only have/can the infamous THEY-THEM use “drugs” but also famous fellow citizens! Psychoactive substances—their users, misusers and non-users-–have been an integral part of man's history and development and are likely to continue to be so … as peers or non-peers.
28 The reader is asked to consider the following. There are many disease models, not just one. These include, among others, biochemical, actuarial, functional, experiential, social, political, religious-spirit-animism, economic and consumer-based models. Secondly, each have their own critical definitions, criteria, goals and agendas, constituencies, indicated and contra-indicated techniques and services, “healers” and change agents, preferred sites for intervention, temporal parameters, and stakeholders. Each have their unique ethics-associated issues.
29 The reader is referred to the concept and the literature of disease mongering.
30 The editors of this Special Issue have most appropriately reminded me that the “peer” concept/tag may be positively valenced in the community and/or on the street.
31 An illegitimate Yes-No answerable question which can lead to a consensus, or not, but not to needed paradigmatic breakthroughs.
32 A legitimate, a-la von Foerster question which may or may not be of interest to you, the reader.