Rats in a Cage: Powerlessness in Addictions Treatment for underprivileged women

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Rivkah Lapidus, Ph.D.,  2011

For a few months in 2009, I held a difficult but enlightening supervisory position in a 28 day, publicly funded residential addictions treatment program for homeless and traumatized women.  Like many programs of its kind, the program was highly structured, intense and restrictive. The experience led me to these reflections.

Thirty women were seated-- sprawled, slouched-- in folding chairs arranged in an irregular circle in the Group Room. It was the daily Morning Meeting. Slowly around the room, the "check-ins" proceeded. "I’m Mary; I’m an alcoholic and a drug addict. My goal for today is…" I was overcome by a sense of lassitude and apathy. The room was overheated, the recitations drained of animation, and my mind inevitably wandered.  An image formed in my mind of a cage-- filled with thirty lethargic laboratory rats.  I recalled a paper I had once read, "Rat Park Chronicle" (Alexander, Coambs, and Hadaway, 1980), describing a study in which rats caged in extremely stressful conditions persistently sought drinking water laced with opiates, while more pampered rats set up in an environmentally lovely "Park" said "no" to the morphine and drank plain water. 

“I’m an alcoholic and a drug addict.” That admission is the First Step of the Twelve Step recovery program, which is the preeminent paradigm in addictions treatment. The language of the 12-step movement is so embedded in the addictions field, the clinical world and popular culture that it is difficult to talk about addictions with any other language. The 12-step system goes hand-in-hand with the Disease Model of Addiction, a model I will discuss shortly.

The 12-step approach to recovery (Alcoholics Anonymous, 1939/1976), with its expansive network of groups and traditions is a lifeline to many thousands of people. It would be absurd to belittle it. Many who have struggled with addictions and are “in recovery” find that surrender of the illusion of control is paradoxically empowering, shifting their values and focusing them on what is truly important in life.  I often everyone, not just the addicted, would benefit“working the Steps,” and that they should be required of all those who seek election to political office. 

 

Acceptance of one’s essential powerlessness in the universe is a complex idea that runs through many spiritual traditions.   But I began to suspect that something less benign happened to the profound message of powerlessness as it was woven into this women’s treatment program.  For these women, there was a darker side to “powerlessness” –a shadow of helplessness, frustration and defeat. Many came from chaotic and violent lives, poverty, homelessness, prostitution, or jail. Loss of custody of children was a commonly shared heartache. Sometimes, these difficulties had haunted their communities for generations.

 As the Morning Meeting wore on, and through many Morning Meetings afterward, I wondered generally about the assumptions embedded in addictions treatment. I thought about the opiate-craving rats, and about what it means to be powerless. I came to the conclusion that in programs such as this one, serving a marginalized population of women at the bottom of our society’s social and economic scale, treatment is enacted in a kind of cage, recreating the environmental stresses of the larger social system, not only because of its specific physical discomforts, but in the way it more subtly expressed our society’s anxieties about addiction.  

 

The disease model of addiction  is the dominant paradigm in mainstream addictions treatment . In past centuries, addiction (and insanity overall) were attributed to demonic possession (Szasz, 1970) and so invited loathing and condemnation. Well into the twentieth century, addiction implied moral degeneracy and criminality  So this more scientific understanding of addiction as a medical disease, like diabetes or cancer, has been widely embraced as an advance over the stigmatizing attitudes of the past (Jellinek, 1960; Waters, 1991). The medical approach is arguably a more compassionate way of thinking than the moral or criminal framework, placing the problem squarely in the arena of public health. This disease may be something an individual “has” innately. “I have an addictive personality.” A genetic predisposition is assumed.   Perhaps an individual “gets” the disease when certain substances are repeatedly ingested and the brain is irrevocably changed (Leshner, 2001). At last, individuals are longer blamed- or so it would seem.      

The social deviance paradigm is still alive and well, as our prisons filled with drug offenders will attest.  Perhaps in our culture there is shame in having any kind of disease (Goffman, 1963; Sontag, 1974).  But there is something uniquely unsavory (it is felt) about addicts. Biologically afflicted at first, the full-blown addict has become a moral and spiritual failure who has chosen to perpetuate the disease and who must be dealt with harshly. Thus, the disease concept thinly disguises centuries-old moral condemnation, dressing up old stigmas in laboratory clothing. Scientific at first sight, the die-hard prejudices remain (Acker, 1993; Peele, 1989; Veatch, 1973). 

But it seems to me that use of the disease concept, like the concept of “powerlessness” has different implications in different settings.  For in whom does the disease lie? As people “work the steps” of recovery, they confront personal demons and character. But what about the social conditions in which their addictions had flourished? 

 

The prevalence of the topic in the media, the introduction of new prevention programs and strategies, the urgency of discussion among parents, lawmakers, and educators, the rhetoric of the “War on Drugs,” all seem to reflect the society’s frustration at its inability to control and contain the proliferation of substances  and other objects of addiction, and reflect our fear. 

 

It is not only the afflicted individuals who are powerless. As clinicians, we too have absorbed our society’s fears and anxieties about addictions. Many of us have heard a lot about “this population” and are frankly intimidated. Many who work with all manner of psychological distress, trauma and psychosis decline to work with substance abusers because they are known to be fundamentally dishonest and manipulative.   

For the Psychodynamic Clinician

Psychodynamic theorists have made important contributions to the understanding of addictive behavior. We place addiction within the scope of our expertise, rather than designating it a problem to be dealt with only within the medical or penal system (Blatt, McDonald & Sugarman, 1984).  Khantzian’s “self-medication hypothesis” (1985) argues that drug users settle on a “drug of choice” because of inherent properties that soothe painful affect states and compensate for “deficits in self-care.”  We now recognize our familiar psychoanalytic turf!       

   But as we welcome psychological sensitivity to the problems of addictions, must we limit ourselves to locating the disease within the individual? I don’t believe so. It is quite within the territory of the psychoanalytic school of thought --consider the neo-analysts of the 1930’s and 40’s (e.g. Horney, 1937)-- to consider the primacy of  societal factors in the origins of psychological suffering.  Drug users may indeed “self-medicate,” but the painful affects and deficits from which they seek relief do not arise independent of any social context (Lindesmith, 1938). As we work competently with individual psychological issues, it is important that we recognize the social attitudes and conditions that not only maintain the stigma attached to addiction—but may actually generate and perpetuate the addictions themselves.                Attachment theory (Bowlby, 1969; 1970) offers an opportunity to consider the larger social frame that is not readily apparent in more traditional perspectives, even ones that privilege relational development.  Some cite addiction as a manifestation of an individual’s attachment disorder (Flores, 2004) reflecting developmentally based anxious and insecure attachments, but I think that formulation also runs the risk of too narrowly focusing on the individual. (An anxious  hyper-focus on the mother-infant dyad  has morphed into this comtemporary thing called “attachment parenting,”  with diaper-free babies who are weaned at 3 or 4—but I digress). the social significance of the theory is lost. 

Bowlby’s original work had its genesis in the trauma British children were subjected to in the Second World War… Attachment theorists are keenly aware of the cultural roots of anxious attachment within an avoidant society (Karen, 1998; Flores, 2004). They are also aware of the pernicious effect of poverty and deprivation on even a competent caregiver’s ability to provide security and comfort (Main & Hesse, 1990; Main & Solomon, 1990), and of cultural norms ("normative abuse”) that can override maternal instincts for attachment, making attachment security less possible. 

Rats in Cages

Let’s go back to addictions treatment and the experiment of the Rat Park Chronicle. In that experiment, the rats were isolated from one another in stacked, cramped cages, so that they could not feel the community of their fellow rats in neighboring cages. In contrast, residents of the Rat Park were free to roam in a spacious natural setting, and to interact with the other rats. These lucky park dwellers rejected the morphine-water, even though it was temptingly sweetened (rats are known to have a sweet tooth). The caged rats sought the morphine—even unsweetened—in increasing amounts. Their drug craving, according the study’s authors, was a natural response to the overwhelming anxiety engendered by their insecure and fragmented living conditions. 

Of course addictions treatment is for human beings, not rats. But we have something to learn from those creatures.  The “Rat Park” experiment provides a way to understand the power of social conditions in generating and perpetuating addictions.  The rats’ compulsive consumption of opiate-laced water did not arise from individual genetic, psychological, or spiritual disease. Rather, acute environmental stress, both physical (the cramped conditions) and psychological (the isolation) made conditions ripe for the seeking of relief through substances.

Treatment, ideally a respite and a place to acquire tools to manage life’s difficulties, becomes something quite different when applied to those who are marginalized in our society. A moralistic point of view clings unacknowledged to the treatment structure, increasing caregivers’ potential for punitive attitudes, anger and blame.  Thus treatment mimics the conditions which gave rise to the addictions in the first place.   

  The women who came to the treatment program I experienced had lived their lives in "cages" of extreme social situations of one kind or another. The poor have few, if any, treatment options. They do not have adequate health  insurance, or families with deep pockets.  They do not choose treatment programs from brochures.      

 But in our world, who lives in a ‘park? ” Family violence, sexual abuse, emotional alienation and neglect, know no class boundaries. Even normative, non-traumatic environments are fraught.  For some, there is obvious economic and cultural poverty. For others,  there is a poverty of intangibles-- compassion, resources, connectedness, hope. Even the "secure base" of a balanced  ecosystem  has been damaged.            As social beings, we all require the basics: health and safety, freedom to explore, and the sustenance of community.

            What has all this to do with us, empathic and  relational clinicians in offices, who may be far away from the  particulars of the addictions treatment world?  We too may act on our fear and helplessness because of what we have learned about addicts, rejecting them refusing to treat them, or expressing disdain in subtler ways (Freimuth, 2008). As we work competently with individual psychological issues, a crucial factor is missing from our work if we are blind to socio-cultural context that maintain stigma and generate dis-ease-- addictive or otherwise. The cage constructed around us is not always visible.

 

References: available on request