“Read My Lips”—Empty Words: The Semantics of Institutionalized Flawing

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Notes

¹ The reader is reminded that the concepts of “risk factors,” “vulnerability,” “susceptibility” as well as “protective factors,” are often mentioned in the literature, without adequately noting their dimensions (linear, nonlinear; rates of development and decay; anchoring or integration, cessation, etc.), their “demands,” the critical necessary conditions (endogenously as well as exogenously; from a micro to a meso to a macro level) which are necessary for such complex, dynamic, multidimensional processes to operate (begin, continue, become anchored and integrate, change as de facto realities change, cease, etc.) or not to, and whether their underpinnings are theory-driven, empirically based, individual and/or systemic stake holder bound, based upon “principles of faith,” doctrinaire positions, “personal truths,” historical observation, precedents and traditions that accumulate over time, conventional wisdom, perceptual and judgmental constraints, “transient public opinion,” or what. This is necessary to consider and to clarify if these oft used and misused terms are not to remain as yet additional shibboleths in a field of many stereotypes, tradition-driven activities, “principles of faith,” stakeholder agendas and objectives as well as ongoing flaws. Editor's note

² The reader is asked to consider that the term “recovery” is an overloaded container concept which is bounded by culture, time, place, and stakeholder values. Although there is no consensualized definition by a range of involved deliverers of care and services for its targeted populations a most recent effort to define it has resulted in the following definition: Recovery is defined as a voluntarily maintained lifestyle composed characterized by sobriety, personal health, and citizenship. The Betty Ford Institute Consensus Panel, Journal of Substance Abuse Treatment 33 (2007) 221–228. “Recovery” is most often associated with abstinence. Its dimensions, and the necessary internal and external, micro and macro level conditions for its achievement, and sustaining it, in treatment ideologies such as harm reduction, quality-of-life, and conflict resolution have yet to be delineated. Editor's note. UK

³ There is the need to distinguish between pharmacological action, and ones “drug experience,” which is the outcome of the complex interactions between, the chemically active substance, the user, and where it is being used, or site. [Zinberg (1984)].

⁴ The reader is referred to a relatively new mega-environmental concept and process—“big events-–which is posited to be relevant to a drug use trajectory. This new term, introduced into the recent intervention literature (Samuel R. Friedman, Diana Rossi, Peter L. Flom. (2006). “Big events” and networks: Thoughts on what could be going on. Connections 27(1): 9–14.] refers to major events such as mega-–disasters, natural, as well as man-made, famine, conflict, genocide, disparities in health, epidemics, mass migrations, economic recessions, etc. which effect adaptation, functioning, and quality-of-life of individuals as well as systems. Existential threat, instability, and chaos are major dimensions and loss of control over one's life is experienced. The necessary conditions for the operation of the noted “big event,” and its temporary or more permanent effects, at various levels and qualities, and what can be done to prevent or to minimize such effects, have yet to be sufficiently assessed. Editor's note

⁵ Treatment can be briefly and usefully defined as a unique, planned, goal directed, temporally structured, multidimensional change process, of necessary quality, appropriateness, and conditions (endogenous and exogenous), which is bounded (culture, place, time, etc.) and can be categorized into professional-based, tradition-based, mutual-help based (AA,NA, etc.) and self-help (“natural recovery”) models. There are no unique models or techniques used with substance users-–of whatever types and heterogeneities-–which are not also used with nonsubstance users. Whether or not a treatment technique is indicated or contraindicated, and its selection underpinnings (theory-based, empirically based, “principle of faith-based, tradition-based, etc.) continues to be a generic and key treatment issue. In the West, with the relatively new ideology of “harm reduction” and the even newer Quality of Life (QOL) and wellbeing treatment-driven models there are now new sets of goals in addition to those derived from/associated with the older tradition of abstinence driven models. Conflict-resolution models may stimulate an additional option for intervention. Each ideological model has its own criteria for success as well as failure as well as iatrogenic-related harms. Treatment is implemented in a range of environments; ambulatory as well as within institutions which can include controlled environments Treatment includes a spectrum of clinician–caregiver–patient relationships representing various forms of decision-making traditions/models; (1) the hierarchical model in which the clinician-treatment agent makes the decision(s) and the recipient is compliant and relatively passive, (2) shared decision-making which facilitates the collaboration between clinician and patient(s) in which both are active, and (3) the “informed model” in which the patient makes the decision(s). Editor's note

⁶ The reader is asked to consider that Substance Use Disorder Drug (SUD) is a relatively new diagnostic category (APA, 1995; 2013) which is the outcome of a recent check-listing process of medicalizing and “symptomizing” a range of human behaviors which is based upon expert committee consensualization of perceptions, judgments, and decision-making. It is a labeling process based upon 11 criteria (APA, 2013) which deal with time, a person's experiences, impaired judgment, prosocial role malfunctioning, negative effects on a range of prosocial activities and the introduction, and dependence, upon two concepts-–tolerance and withdrawal. These terms represent the development of “drug” use-related processes which are not delineated in terms of their pharmacological actions on the microcellular level from a macro ”drug experience,” which is the outcome of the dynamic interaction between the actual active “natural” or man-made chemical, the user, and the site of use at a given point in time. (Zinberg, N. E. (1984). Drug, Set, and Setting: The Basis for Controlled Intoxicant Use. New Haven: Yale University Press) The Substance Use Disorder is not evidence-informed. Nor are any of the other diagnoses in this pathologizing nosological system. A useful diagnosis, which is the outcome of collecting relevant materials, over time, and which are culture-context and situation sensitive, in order to make a needed relevant decision, should, at the very least, enable an understanding of etiology, prognosis and process of the posited “disease” or condition for effective treatment planning, implementation, and assessment. Editor's note

⁷ The reader is asked to explore the notion of “normed use” within a conceptual framework of learning to be … a user as well as a non-user, in terms of: for whom is it permitted …for whom is it forbidden …for whom is it an obligation …for whom is it a need …for whom is it a choice? Editor's note

⁸ The expected relapse to substance use, associated with the medicalized pathologizing of a “homogenized” substance user, whose qualities and levels of daily adaptational and functioning resources in a range of roles, contexts, situations, networks, and environments is rarely considered or studied; a flaw. The reader is referred to Diacu for a stimulating review of the accuracy of human prognostication; “fancy predictions.” (Diacu, Florin, 2010, Mega disasters: The science of predicting the next catastrophe. Princeton: Princeton University Press). It is interesting to consider the implications of diagnostic semantics; treated cancer patients—another “homogenized” population given the types of cancers, their various states, and dimensions are related to in terms of posttreatment remission and not relapse MAY achieve some state of recovery, never remission, but are expected to relapse; even expecting this of themselves. There was a time when the three R's, at least in American English, meant reading, “riting” and “rithmatic”…when “users” were sinners to be saved, before they became criminals to be “carcerated” or “sickies” to be treated in a WE-THEY weltanschaaung. Editor's note

⁹ When considering addiction “experts” and “specialists,” it may be useful to explore the point-of-view of Robert A. Heinlein, an American science fiction writer, often called the “dean of science fiction writers” who noted that a human being should be able to change a diaper, plan an invasion, butcher a hog, conn a ship, design a building, write a sonnet, balance accounts, build a wall, set a bone, comfort the dying, take orders, give orders, cooperate, act alone, solve equations, analyze a new problem, pitch manure, program a computer, cook a tasty meal, fight efficiently, die gallantly. Specialization is for insects. Editor's note.

¹⁰ The term “community” has become something of a policy buzzword which has been attached to a diverse range of ideas and initiatives. It means various things to a range of individual and systemic stakeholders. “Shared geography,” as an often-regarded simplistic, common denominator, minimizes the range of other “sharing” options which range from actual objects to beliefs, values, membership in, identification with, association with, from a micro to a globalized macro level. One can categorize in very (over)—simplistic terms-–three “types of community intervention models” for as one considers the “demands” and implications” of community readiness and community awareness for planned intervention. Professional network: professional networks made up of agencies which are responsible for coordinating efforts around the goals set by central government. Based on expert knowledge and professionally defined codes and protocols, these networks often leave little room for involvement of those outside the professional group. Community partnership: where community members and professionals come together on a more or less equal footing, forming a community partnership. Valued professional expertise is joined with community views. Community members-–who most generally represent a small and organized group and not the community's heterogeneity-–have genuine influence and are actively involved in decision-making processes. Grass-roots community initiative: in which members of a community come together over a particular issue which they consider to be important. The group's meeting and other activities are not defined by professional interests, which may, over time, evolve into a community partnership. Drug user groups in Europe and other parts of the world are examples of this. The reader is referred to Shiner, et al (2004) Exploring community responses to drugs Joseph Rowntree Foundation, York, UK (www.jrf.org.uk) for a stimulating analysis of community intervention. Editor's note.

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Notes on contributors

Zili Sloboda

Zili Sloboda, Sc.D., US, currently is the President of Applied Prevention Science, Inc. She was trained in medical sociology at New York University and in mental health and epidemiology at the Johns Hopkins University Bloomberg School of Public Health. The majority of her research has been related to the delivery of health-related services to youth and adults and epidemiology. She is an expert on the prevention of substance use by adolescents and has broad experience in research related to at-risk youth and to the evaluation of treatment and prevention programs. She has served on the faculties of Johns Hopkins University Bloomberg School of Public Health, the University of Illinois School of Public Health, and until 2009, The University of Akron. Prior to this last position, Dr. Sloboda worked for twelve years at the National Institute on Drug Abuse in several capacities, finally as the Director of the Division of Epidemiology and Prevention Research. This Division's focus was on the development and support of national research programs in HIV/AIDS epidemiology and prevention and drug abuse epidemiology and prevention and at the time had the responsibility for several large national epidemiologic and treatment data systems. She was a founder of the US and EU Societies for Prevention Research and is well-published in the area of drug abuse epidemiology and drug-use prevention. Her three major books include the Handbook of Drug Abuse Prevention, Epidemiology of Drug Abuse, and Defining Prevention Science. In addition, she has a long standing commitment to the dissemination of evidence-based programming and the advancement of Translation I and II research through work with the Society for Prevention Research and current work with the United Nations Office on Drugs and Crime to develop international standards for drug use prevention based on research evidence and training workshops for policy makers. Her current focus is on developing and testing curricula for the training and licensing of an international cadre of prevention coordinators and specialists in collaboration with The Colombo Plan's International Centre for Certification and Education of Addictions Professionals with funding from the US Department of State. Through this program, prevention professionals from Asia, Africa, Latin America, the United States, Canada, and Europe will be trained and licensed to deliver evidence-based substance use prevention interventions.