Drug treatment and rehabilitation - Eurad · Web viewMy lecture will consist of the following: ... they are not suffering from a compulsive disorder and they are not forced to ...

Drug treatment and rehabilitationin The Netherlands

DRUG AWARENESS AND ADDICTION PROGRAMME 21-25 SEPTEMBER, 2015, AMSTERDAM

Frans Koopmans (De Hoop Foundation)Monday, September 21, 2015 (13.00-14.00)

Good afternoon, ladies and gentlemen,

First of all, I want to thank the organizers of this EURAD ‘Drug awareness and

addiction programme’ to be able to share with you some thoughts on the subject of my

speech: ‘Drug treatment and rehabilitation in The Netherlands’.

Let me first introduce myself: my name is Frans Koopmans. Since 1987, I have been

working at De Hoop Foundation (The Hope) in the Netherlands. De Hoop is an

abstinence based Christian psychiatric hospital for addiction care. Since 1975, we have

been helping hard drug, alcohol, medicine and gambling addicts on the way to a life

free from addiction. My own specialty lies in the study of addiction and addiction

policy.

Introduction

In dealing with substance use and addiction, two approaches can be thought of.

Rehabilitation and punishment. Two approaches of addiction that at first glance seem

mutually exclusive. Rehabilitation aims at restoring the addict to good health or a

useful life, f.e. through therapy and education. This approach often starts from the

premise that addiction is primarily a health problem. Punishment, on the other hand, is

imposing a penalty for wrongdoing, in this case the use of illicit drugs resulting in

addiction, where the basic premise is, that addiction is a legal problem. As I said, they

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seem mutually exclusive. However, in reality, both approaches go together.

Punishment can be part of rehabilitation, and vice versa: rehabilitation can be part of

punishment. The two approaches do start, though, from different perspectives as to

what exactly constitutes the origin and nature of addiction and drug use.

Drug use and addiction are, then, remarkable phenomena. One may well wonder how

the same phenomena can be addressed punitively as well as medically. Harvard

professor Gene Heyman in his 2009 book ‘Addiction, a disorder of choice’ writes, and

I quote:

[quote] “We typically do not advocate incarceration and medical care for the same

activities. Indeed, addiction is the only psychiatric syndrome whose symptoms – illicit

drug use – are considered an illegal activity, and conversely addictive drug use is the only

illegal activity that is also the focus of highly ambitious research and treatment

programs.” [end of quote]

Drug use and addiction have a legal as well as a medical side to them simultaneously.

Which side prevails in drug policy depends on the specific view that one holds of the

nature of drug use and addiction, the person of the addict and the circumstances in

which addiction and drug use take place: a public health approach when one regards

addiction predominantly as a health issue, a legal-punitive approach when one regards

addiction predominantly as an illegal activity. Underlying this dilemma is the question:

can an addict really be held accountable/responsible? The answers differ, depending

on the perspective one uses.

In my presentation, I will try to delve somewhat deeper into this dichotomy of

rehabilitation versus punishment. My lecture will consist of the following:

1. Bird’s-eye view of different perspectives on addiction

2. Ways out of drug abuse – some suggestions

3. Drug treatment in the Netherlands

4. Concluding remarks

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1. Bird’s-eye view of different perspectives on addiction

Let me first state that the addiction problem with which we are confronted today of

course cannot simply be brought back to the aforementioned polarized positions of

rehabilitation or punishment. Addiction is a multifaceted problem that includes more

than either health or legal considerations, important though they be. The basic problem

with addiction policy and addiction care seems to be that there have been and still are

widely divergent perspectives on what addiction in fact is, i.e. what its defining

characteristics are, as well as what would be appropriate responses. Historically, there

have been different views as to what exactly constitutes the essence (the origin, nature)

of addiction and the addiction problem (Van den Brink 2005). As a result of this,

addiction was and is dealt with in different ways.

Since the mid-18th century there was a change in the way addiction and addicts were

regarded. At first, addiction was primarily seen as a moral weakness: the moral model.

The addict (the one showing habitual drunkenness) is weak and a-moral, i.e. morally

wrong. As from practice it is clear that he not a automaton and is able to refrain from

taking drugs or drinking alcohol, there is sufficient reason not to seek and use

drugs/alcohol. This latter intentional behavior points to the fact that one may morally

assess this phenomenon. That is to say, may be the object of evaluation regarding

responsibility. The normative criteria of this responsibility are a general capacity for

rationality and a lack of unjustified compulsion (Morse, 2004). The solution for the

addiction problem within this paradigm was sought in prison or a re-education camp.

Though the view of addiction has been a-moralized over the last couple of centuries,

there are still proponents of this model to be found today.

With the rise of medical science in the second half of the 19th century, one gradually

came to see the addictive substance as the main cause for addiction: the

pharmacological model. The kernel of the problem was now seen lying in the

substance, not in the person. The solution for the addiction problem was now sought in

prohibiting the addictive substance . By prohibiting the addictive substance it would

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not be readily available. In the 30’s of the previous century, subsequently, this

pharmacological model, though politically still in place, was gradually replaced by a

model that emphasized that addiction was to be regarded as the symptom of deeper

underlying personality or character problems. Those problems needed to be addressed

by psychotherapy: the symptomatic model. The addict is suffering from a personality

disorder. Psychotherapy, for example in therapeutic communities, is seen as the

appropriate solution, aiming at furthering understanding in the addicted person.

In the period 1940-1960’s, the disease model gained popularity: addicts are those

persons who are – compared to not-addicted persons and based on their biological and

psychological characteristics – much more vulnerable for addiction. “According to this

model, there are fundamental (premorbid) biological and psychological differences

between addicts and non-addicts. Therefore, the former are not capable to use drugs

and alcohol moderately.” Addiction is described in terms of loss of control and

physical dependence (‘tolerance’, ‘withdrawal symptoms’). The solution is seen in

lifelong abstinence, for example via self-help organizations as Alcoholics Anonymous

and treatment based on the Minnesota Model.

From the 1960’s onwards a new psychological perspective on addiction came to the

fore: addiction as a form of learned behavior: the learn theoretical model. Basic to this

perspective is that behavior that has been learned, can also be ‘un-learned’, including

addictive behavior. The therapeutic approach is here in the form of cognitive

behavioral therapy and cue-exposure therapy.

What the perspectives mentioned above have in common, is that one focusses on one

aspect of addiction, that is subsequently being seen as explicative for the problem.

Increasingly, however, the awareness gained ground in the 1970’s and 1980’s, that

restricting the explanation of addiction to just one of its aspects doesn’t do justice to

the multidimensional nature of addition. This concept of a multidimensionality of

addiction meant an adjustment – even correction – of the one-dimensional approaches

that had been prevalent up till then. Researchers and treatment providers alike realized

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that in order to gain a more truthful, more integrated picture of addiction all relevant

aspects of addiction should be taken into account simultaneously. One discovered that

apart from biological and psychological causes, also social circumstances play a role in

the development of addiction. This finally led to the bio-psycho-social development

model, that we have today. The model holds that for the development of addiction,

apart from the addictive substance, not one cause can be given, but that different

factors at the biological level (i.e. genetic predisposition), the psychological level (i.e.

dysfunctional thoughts and behaviors) as well as at the social level (i.e. disturbed

relationships, problems with housing) determine whether someone becomes addicted

or not. In order to address the addiction problem one needs to take into account all

these levels via multimodal (integrated) interventions.

Since the 1990’s there seems to have occurred again a return to a much more one-

dimensional approach towards addiction: addiction as being primarily a brain disease,

i.e. a making absolute the ‘bio’ aspect of addiction. On the waves of brain research,

research into addiction now predominantly consists in brain research.

Table 1: Short history of the concept of addiction1

Period Dominant Addiction

Model

Matching treatment

1750-now moral model prison, re-education camp

1850-now pharmacological model Prohibition of alcohol and drugs

1930-now symptomatic model psychotherapy en therapeutic communities

1940-now disease model Medication and AA

1960-now learn theoretical model (cognitive) behavioral therapy

1970-

1990

bio-psycho-social model multi-modal therapy

1990-now brain disease model Medication and (cognitive) behavioral

therapy

1 Based on (Van den Brink, 2006), 60

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But can we say now that we have seen the light and that, yes, addiction is indeed a

biomedical problem, a chronic relapsing brain disease? Even though the majority of

addiction scientists now submit to this model, the question is far from being settled.

The question what constitutes addiction is, as far as I am concerned, still not answered.

And perhaps even cannot be answered conclusively. One of the problems with

emphasizing one aspect of the addiction problem is neglecting other equally relevant

aspects. In scientific literature, there are almost as many perspectives as there are

addiction scientists. Each of these perspectives in principle provides legitimate, though

inevitably from the nature of things, limited views of what constitutes addiction.

Emphasizing specific aspects of addiction and neglecting others may hamper an

integral, comprehensive (‘holistic’) view of addiction.

To get back to rehabilitation or punishment, or rehabilitation instead of punishment:

we have seen that there are many more perspectives than just the biomedical or the

punitive ones. Still, for our discussion they can serve as examples. Both provide a

specific interpretation of accountability: the question whether an addict can be held

responsible if he does something wrong, or that that is not the case; because the addict

suffers from a chronic relapsing brain disease which negatively influences his capacity

for decision making and behaving morally. There is a lot of literature dealing with this

question, also in the broader discussion whether you and me are completely

determined by our brains. For if that is the case, the ultimate conclusion has to be that

you cannot be held accountable. ‘For my brains did me do that…!’

Disease model

Elementary to a disease model of addiction, is the notion that addictive behavior is

compulsive. Compulsion is doing something because one experiences one has to do it.

The urge is irresistible. One does the specific act repeatedly and is unable to stop it. It

is not something that you do out of free choice. So, where addiction is defined as a

‘chronic relapsing brain disorder’ compulsion is central. The idea is that addicts,

because of their addiction and the inherent lack of concern for their health are viewed

as being mentally incompetent to make real choices or to consent to whatever. They

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suffer from decisional impairments, from invalidating decision-making capacities.

Disease, then, seems fully incompatible with the responsibility of the addict. Perhaps

responsibility for the disease of addiction can be applied to the beginning stages of the

disease. But ‘disease’ consists of irreducible, pathological mechanisms in the body

over which conscious choice does not have sway. “The signs and symptoms of the

disease […] are seemingly the mechanistic consequence of pathological biological

structures and functions over which the addict has no control once prolonged use has

caused the pathology.” Connected with compulsion, is the opinion that addicted drug-users contravene their

true desires. One has to differentiate here between so called first and second order

desires. According to Harry Frankfurt “addicts are not free because they have a first

order desire to take heroin but a higher second order desire not to desire to take heroin.

[…] Freedom of the will occurs when our first order desires are in line with our second

order desires: we do what we desire to desire to do.” In the case of the addicts, from

the perspective of the disease model, one can speak of autonomy impairment. There is

a conflict in the volitional hierarchy of the person: the person does something that he

really does not want, so he acts against his will: “Addicts change their minds: the

opportunity for consumption arises, or the cravings begin, and the pleasures of the

drugs begin to weigh more heavily with them than the goods achievable through

abstaining.” So, the addict seems to sacrifice his longer term interest by giving in to

his shorter term interest, i.e. the use of drugs. Even though he might originally have

opted for the longer term interest, there occurs a judgment shift in the addict where he

ends up in choosing for the immediate gratification of the desire. The latter seems to

him at that specific point of time to be more ‘rational’ than choosing abstention. By

sacrificing his shorter term interests for the longer one, he would have been capable of

pursuing his own conception of the good.

Levy (Levy 2006b) describes the addict as a less unified self, as somebody who is

unable to effectively exert his will across time, as somebody who is lacking the

capacity for self-government, which shows itself in preference reversals. Lack of an

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unified self can be compared to the empirical experience that addicts stop their normal

development the moment they start using drugs. Their selves are more fragmented

(‘disunified’): “They lack the capacity to unify themselves to a sufficient degree to

begin to formulate plans and policies, in the realistic expectation that they will abide

by them.” And so they are less able to delay gratification. Levy (Levy 2006a; Levy

2006b) brings in here the notion of ego-depletion. Even though he does not fully agree

with the notion that addiction destroys all autonomy, he still holds on to a certain

measure of autonomy impairment: “After all, not only is there the phenomenological

evidence, to which many of us can attest, that breaking addiction is difficult, there is

also the evidence that comes from the fact that addicts slowly destroy their lives and

the lives of those close to them.” Ego-depletion, Levy states, causes self-control over

time to diminish. The length of time this takes depends on how much self-control

resources are there in the life of the addict and how much of those resources are spent.

What addicts need to do, then, is take care to avoid cues that trigger craving. For,

within the disease model, it is the craving that makes addicts give in to their first order

desires and thereby squander their true good. Addicts still have some basic autonomy,

Levy holds, “the minimal status of being responsible, independent and able to speak

oneself.” But where true autonomy (or: ideal autonomy; or: maximal authenticity)

consists essentially in the exercise of the capacity for extended agency, addiction

undermines this “so that addicts are not able to integrate their lives and pursue a single

conception of the good.” Caplan (Caplan 2008) holds that an addict might be capable

of, what he calls, reason-autonomy, that is being able to make decisions, setting goals,

etc. But according to him this is not sufficient for autonomy. “Being competent is a

part of autonomy, but autonomy also requires freedom from coercion.” This would

make (temporary) infringement of autonomy possible in order to restore long term the

autonomy of the person!

Does addiction create a defect of the will? A defect of the will means that the actor

cannot choose otherwise. This only counts when the actor’s choice is inconsistent with

his ordered preferences, with his higher desires, so: against his will. The addict knows

the choice he ought to make, he also wants to make that choice, but he is unable to

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take the course of action or it is unreasonably difficult for him to do so. So, it seems to

be a matter of compulsion, the state that addicts literally cannot resist their urge to

procure and take the drug. However, does compulsion really exist? Levy denies this.

The idea of the unwilling addict is a myth, he states. There is no such person “because

there is no such thing as an irresistible or compulsive urge to consume drugs, and

because the addict who is moved by a force which is wholly alien to her is a myth.”

Addiction provides the motives for action, certainly, but that is not equivalent to

saying that those motives are irresistible (i.e. compulsive). The addict is not helpless.

Summarizing, we can say that a disease model of addiction emphasizes compulsion

and loss of control that seems hard to equate with full blown autonomy. Instead, it

advocates a position of non-autonomy or, at best, reduced autonomy.

Disorder of choice model

Basic to a disorder of choice model is that – contrary to the disease model – addiction

is not compulsive. In a disorder of choice model, one holds to the notion that addicts

are morally responsible persons who are quite able to make rational, volitional choices.

As Foddy & Savulescu (Foddy and Savulescu 2006a) indicate, “the evidence that drug

users do in fact respond to powerful incentives is a strong indicator that their behavior

is not compulsive”. As also Levy (Levy 2006b) points out, “[I]f addictive desires were

compulsive, it is difficult to see how addicts could give up voluntarily”. And when

addiction is not compulsive, i.e. when addiction/addictive desires is/are not irresistible,

it follows that addicts cannot be regarded as ‘mindless automata’ that are forced to act

on the basis of the cravings the lack of drugs produce. And when the desires are not

irresistible, it means that addicts are not deprived of their possibility to make volitional

choices.

In an earlier article, Levy (Levy 2003) states that the core issue of (the continuation of)

addiction is not craving or compulsion; the use of drugs is better explained by the

mechanism of hyperbolic discounting, by existential dependency and by life problems.

The first refers to the mechanism that rewards that are closer to us in time gain the

preference over the rewards that are more long term. The second points to the fact that

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the addict forms his life around the drug, and that the drug in its turn provides the

framework for living. The last refers to the observation that the consumption of drugs

is a way to deal with life’s problems, only “an extremely flawed solution.”

According to Foddy & Savulescu (Foddy and Savulescu 2006a), addiction is not really

much different from drug-oriented and other appetitive desires, like eating, only it is

stronger. And whereas appetitive desires must be considered valid sources of rational,

volitional choice this also applies to chemical addictions. So, in their opinion, choices

of addicts, even when desiring drugs, are authentic choices: “It may be that desire for

drugs harms a person or leads a person to do what he has good reason not to do, but we

should not say these desires are unreal or inauthentic.” Within a disorder of choice

model a conclusion can be upheld that, contrary to a disease model, addiction is not

compulsive and that addicts keep on exercising some degree of control over their

consumption behavior. They are still in the possession of their volitional resources.

Addictive behavior is intentional behavior, i.e. the addict plans, purchases drugs,

consumes them, etc. And all these acts are deliberate acts. And that is equivalent to

saying that it is his choice to do these things. “That is precisely what makes addiction

such an interesting issue in the study of responsibility: the addict knows what she is

doing and chooses to do it, and yet we want to say that, in some sense or other, she is

not in control of her behavior.”

Even when we would recognize disease elements in addiction – which in our opinion

can be admitted – “[t]he presence of a disease per se does not answer the question of

responsibility within a moral and legal model, even if the presence of the disease and

its signs and symptoms are uncontroversial.” One can even admit, with Levy, that

there is a measure of autonomy impairment in the addict. But how does one measure

the impairment of autonomy? As Husak (Husak 1999) holds, “the amount of

autonomy that must be lacking in order to excuse an act may not be identical to the

amount that must be lacking in order to justify its proscription.”

Contrary to a disease concept, within a disorder of choice model addicts are not

regarded as automatons. That is to say, addicts are not determined to (continue to) use

drugs. When an addict is able to make other choices, it means he is not determined,

that he is free to choose. Corrado (Corrado 1999) differentiates as to a defect of the

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will between those who hold to the notion and those who don’t. The first are those

who hold that the person cannot choose otherwise, which he equates with the position

of the disease theory of addiction. Those who hold the latter position (i.e., that there is

no defect of the will) he subdivides in those who hold to rational addiction (addiction

is just behavior as any other, rationally pursuing an increase in pleasure (or utility),

and so has no bearing on responsibility), addiction as duress (addiction is a rational

response to a coercive situation and so is not responsibility after all; addiction serves

as an excuse, rationally avoiding pain) and addiction as distortion, as a defect of

rationality (the addict’s behavior is irrational in the sense that he brings about

consequences that he would prefer not to bring about, and fails to bring about

consequences he wants to bring about. So, his beliefs do not respond to the evidence,

distorting the addict’s relationship with reality).

A disorder of choice model denies the metaphor of ‘mechanism’ within the disease

model as “the most misleading source of the intuition that some people cannot control

actions intended to satisfy some desires, especially if we believe that the desires are

produced by neurochemical or other brain abnormalities.” Morse, referring to

Odysseus, argues that the addict has a duty to take steps to bind himself to the mast

“when his desires are less insistent, especially if the addiction-associated behavior is

legally forbidden or if the costs are externalized because the behavior harms families,

friends, and society more generally.”

Up till now in western democracies, the Law in general also does not regard addiction

– and this applies perhaps to most mental and physical diseases – as something that

exculpates the addict when committing criminal offences. The courts have not excused

the addict’s behavior as non-responsible. And that is equivalent to saying that

addiction is not regarded as a disabling condition. And even when it would be

conceded that addiction does infringe on responsibility (i.e. does result in volitional

impairment), it seems impossible for the Law to point out where to draw the

demarcation line. Law does not base itself on the latest biomedical research. The latter

cannot tell how the Law ought to respond. The law as an instrument of social control

must be kept in place.

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Within a disorder of choice model addicts are responsible for their addiction and for

the behavior connected with it. It is the addiction that motivates the person to act. And

the way he does that, is remarkably similar and familiar to the way any human being

acts. “They engage desire, because they promise rewards for drug-ingestion, and

because they promise relief from pain, physical and psychological, whether the pain

that often leads addicts to seek out drugs in the first place, or the pain that is the result

of drug-withdrawal. Addiction provides strong motives for action, but there is no

reason to believe that these motives are irresistible.”39

A disorder of choice, then, negates the compulsiveness of addiction and adheres to the

conviction that addicts make volitional choices, also when choosing to procure and use

drugs. The model recognizes that addicts can be regarded as autonomous in the latter

sense.

Summarizing: there are enough considerations to underpin the notion of responsibility

in the case of addiction. Even though the capacity of responsibility and accountability

may be reduced, the addict is still capable of making volitional choices. That makes

him morally responsible. And that means that punishment may be accorded when

necessary.

Model of existential dislocation (Alexander 2008)

Still, not everything has been said. For even when taking into account the medical

aspects of the addiction as well as the volitional aspects of addiction, we are in danger

of making the so called mereological fallacy: the fallacy of confusing the part with the

whole (or of confusing the function of the part with the telos, or aim, of the whole).

Applied to addiction: saying that de medical aspect is the addiction, or that the choice

aspect is the addiction . We should in my opinion hold to the notion that addiction is a

phenomenon concerning the whole person. And therefore that addiction can be

explained by the term ‘dislocation’, even ‘existential dislocation’. Dislocation stands

for detachment, disengagement, being broken from the moorings. Over against

‘dislocation’ stands ‘psychosocial integration’. But not just psychosocial, I would

submit, but also existential. The existential notion is prevalent here. Like a disorder of

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choice model, this model acknowledges the fact that addicts are morally responsible

agents. They are not victims of their disease, they are not suffering from a compulsive

disorder and they are not forced to use drugs. In an existential dislocation model we

recognize that addicts take drugs because they want to (so, constitutes a volitional act).

Still, their own testimony is that they use against their wills. Levy understands this

unwanted addiction as characterized by an oscillation in the preferences of the addict.

The experience of craving induces a judgment shift in the addict. Still an existential

dislocation model does recognize that more is at hand than just disease or choice.

Within this model addiction is a way to cope with life’s basic issues. That is equivalent

to saying that addiction is in-depth an existential problem, a way of trying to cope with

dislocation.

Both a disorder of choice model as an existential dislocation model refuse to

acknowledge the notion that addiction is equivalent to the hijacking of the brain, as is

assumed in a disease model. In the latter model, in the case of addiction, there is an

impairment of autonomy. The first two models substantiate their view by pointing out

that were addictive desires compulsive, no addict would give up voluntarily. But the

fact is that they do. (Levy 2006b), (Heyman 2009). Where loss of control in a disease

model seems to be connected with non-culpability, in an existential dislocation model

the element of responsibility is upheld. It holds that ‘loss of control’ as an independent

state or condition that undermines responsibility does not gain much support from

related scientific or clinical data. In an existential dislocation model addicts are held

responsible for their addiction and for the behavior that they commit under the

influence. As Watson writes: “Even if addictive conditions are in some (not yet well

understood) way responsibility-undermining, addicts are complicit in their own

impairment.”. And a few pages later: “Citizens have a standing legal duty to develop

and maintain sufficient capacities of self-control to enable them to conform to the

law.”

In an existential dislocation model the possibility of moral choices within an

existential framework is held onto. And with this the dignity of the human being as a

responsible creature. Carrying responsibility is what honors a human being as a human

being. In a disease model the addict is sometimes regarded as a victim. But when the

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addict does not experience the consequences of his own, freely chosen actions, or

when the consequences of his actions are either removed or softened, this can be seen

as incompatible with truly human flourishing. Human life is worth the name where

people who voluntarily engage in specific kind of acts, also experience and are

responsible for the consequences of those actions. Herein consists the dignity of the

human being: that he is a responsible person and can be held accountable for his

actions and the results of those actions. Removing the consequences is equivalent to

diminishing the dignity.

Addressing addiction asks for more than a technical solution to the medical problem. It

means that questions need to be answered as to the purpose of human existence, the

existential questions regarding human life, the questions as to why somebody wants to

avoid pain and pursue pleasure as the highest purpose of life. And such questions can

only be answered by those who have asked those questions first of themselves. One

might even endeavor to say that, in the end, addiction is problem of the heart. But

when the addiction problem is reduced to its technical dimensions, the heart is lost

sight of. Addiction seems much more to be an existential problem. As Dalrymple

remarks: “The addict has a problem, but it is not a medical one, it is an existential,

spiritual one: he does not know how to live.” And when addiction is not a medical

problem, medical interventions will not solve it. Addicts will have to be given a reason

for living.

Dalrymple’s remark points towards a central element in the existential dislocation

model. Even when there would be a (partial) recovery of autonomy, when this

autonomy is not connected with the experience of ‘belonging’, of ‘liberation’, this

concept remains empty. That is to say, when the dimension of meaning is left out of

the discussion, at best we will arrive at superficial solutions that do not do justice to

what a human being is. In a disorder of choice model, these existential notions of

addiction are not part of the concept, just as they are not part of the concept of a

disease model. Only within a model that addresses these deeper issues, justice is done

to what addiction is all about. In an existential dislocation model room is made for

these existential questions that are elementary to addiction, by including spirituality as

a factor in the understanding and treating of addictive behaviors. Here, addiction is

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concerned with the way in which relationships are disordered by making a particular

substance or behavior an object of desire for its own sake. Within a deterministic,

naturalistic view of addiction these aspects of addiction are lost sight of.

An existential dislocation model is a model one might place between a disease model

that perhaps aims too low and a disorder of choice model that perhaps aims too high.

Cook’s theological disorder model (Cook 2006), as a specimen of an existential

dislocation model, tries to ‘normalize’ addiction as something that is inherent in every

human being. By choosing for only a medical view of addiction or, conversely, for only a

moral view of addiction, “we protect ourselves from the implications of admitting the

divisions of self that we experience and yet deny. Instead, we label the addict as either

sinful or sick, projecting on to them the pathology that we disown within ourselves.”

Without denying the medical and moral aspects of addiction, the experience of addiction

then is something that is, as Cook phrases it, “not completely alien to any human being”.

Recognizing that addiction has to do with divisions of the will, with first-order volitions

to continue drug use despite first-order volitions to discontinue, it will lead to the

awareness that only grace (however defined) is able to set people free from their

captivity.

2. Ways out of drug abuse

What has all this to do with the question: rehabilitation instead of punishment? Only

punishment for committed crimes negates what is at stake. An addict is impaired.

Often or almost always existentially dislocated. Rehabilitation must focus on

‘location’ versus ‘dislocation’, on ‘attachment’ instead of ‘detachment, on

‘engagement’ instead of ‘disengagement’. Then what are the ways out of drug abuse?

Rehabilitation. Starts from the premise that addicts can be held accountable but are in

such a situation that they find it hard to make the right, healthy choices. Most of the

addicts that end up in treatment, suffer from comorbidity. But rehabilitation also has to

include addressing the notions of ‘belonging’, of ‘liberation’ and ‘meaning’. They

need to heal from the fragmentation of their identity. As Bruce Alexander states in his

book ‘The globalization of addiction’: “Apparently, there is no pharmacological

antidote to poverty of the spirit” (p.196). Addiction is a problem of modernity where

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conventional wisdom has limited public understanding of addiction to an individual

problem of alcohol and drug use. (Alexander, 206)

So, in my opinion, in the discussion on drugs and what kind of drug policy to pursue,

one cannot escape the broader question of morality, spirituality and the necessity to

ask for the specific philosophies undergirding the different policy positions. However,

this is hardly done. The main line of approach is that of evidence based ideology. The

present day drug discussion, in that regard, seems to be an offshoot of Modernity

where rational (science based) thinking will inevitably lead the way to the correct way

of dealing with the problem and will, finally, result in the appropriate drug policy. This

optimistic, naturalistic approach fails to take into account that more than ‘pure facts’

make up a ‘right’ approach.

A purely medical view of addiction seems to fail in establishing a much needed

holistic approach. Perhaps we have to conclude that present-day central public health

principles of drug policy within a liberal political morality stand in the way of an

integral approach to the addiction problem. However, I uphold that there must be made

room for the element of morality. According to Kinneging (2009) the root of the crisis

of our time is the thinning out of our moral consciousness, our demoralization; that we

have to a large extent forgotten the virtues that morality involves. This applies also to

the way we deal with addiction. By reducing it to a medical condition addiction

appears to have become a controllable phenomenon, but to the exclusion of moral

notions. A remoralization of addiction is necessary. A disorder of choice model

includes moral notions, by emphasizing the possibility for addicts to choose another

life. The addict is responsible for his own life. Without responsibility there is no

individual freedom, at most only adaptation. As Kinneging writes: “If self-constraint

exercised by the conscience is absent, the latter cannot exist. In the words of Edmund

Burke: ‘Without inner control, man is a slave of his passions, his affects. And since

many of those are of an evil nature—they bring disorder, disruption, and destruction—

in the absence of inner control, outer control is required to maintain order and

harmony’”.

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According to some the harm reduction approach has become too individualistic. There

might be some truth in the statement, however, we should take care not to fall into the

other extreme, that the focus should be only on the social. What we need in

considering addiction is an approach that includes both the individual and the social

elements, that is: take into consideration all the subjective elements of addiction and

what addiction means for the social environment. An existential dislocation model of

addiction tries to do just that: it intends to provide an approach to addiction that

includes the biomedical, the psychological, the social as well as the spiritual (i.e.

existential) aspects of addiction. It does not want to restrict itself to the biomedical

aspects nor does it reduce addiction to the social consequences. It purports that the

existential aspects (‘spirituality’) are even the most important ones in considering

addiction. A disease model and even a disorder of choice model stay at the surface of

what constitutes the addiction problem. In the end, the problem of addiction consists of

a deficit of meaning. The existential approach towards addiction serves as the basis for

considering the other (biomedical, social) aspects.

Within a liberal political morality the state must create room where substantive content

can be given to political morality. The state, though it might not opt for one concept of

the good, should take care to establish a kind of substantive minimum with regard to

what constitutes what is good for society. It should not reduce addiction only to public

nuisance or refer it only to the medical institutions, but should encourage civil society

to do its part in tackling the addiction problem. The state should here refrain from an

exclusive neutrality, where it aims at a public arena that is completely free from

religion or any other life ideology – also where it deals with addiction. It should hold

onto an inclusive neutrality where it strives for a public arena where a diversity of

organizations that function on the basis of a religion or life ideology are accepted and

where the latter can function as partner in the execution/implementation of policy. In

this way justice can be done to the deficit of meaning character of addiction.

Meaning refers to the deepest grounds of our human existence. An existential

dislocation model of addiction – and for a Christian, a theological disorder model –

goes beyond the medical, the moralistic and the punitive. In the theological disorder

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model every human being is accepted as being created in the image of God; it deals

with him on the basis of grace and truth. The model acknowledges the human

inclination to evil and does not reduce the addiction problem – or any other problem –

to societal structures. It takes into account that, as Martin Buber says, God has been

eclipsed from the human horizon. And that this has led to the situation that man has

become the measure of all things.

3. Drug treatment in the Netherlands

Dutch addiction care is part of the broader mental health care. This mental health care,

including addiction care, aims at ensuring the availability of high quality, accessible,

affordable and sustainable mental health care. There is a wide variety of services to the

public, ranging from mental health promotion, prevention and primary mental health

care to assisted independent living, sheltered housing, ambulatory specialist mental

health care, clinical psychiatric and forensic institutional care.

Mental health care providers offer counselling, treatment and support to people with

different mental health problems or psychiatric disorders such as anxiety disorders,

depression, addiction, aggression or schizophrenia. The causes and expressions of

these problems vary widely, this calls for many different types of mental healthcare

providers. Some mental health and addiction care providers specialize in a specific

disorder, others provide a variety of services in care pathways, usually offering

prevention, primary mental health care, ambulatory (specialist) care, acute hospital

facilities and long-stay residential care.

The purpose of Dutch drug policy is to prevent drug use and to limit harm to drug

users. In addition, the government takes action to limit the nuisance caused to society

at large. A great deal of information is disseminated about drugs and proper attention

is paid to supervising drug users.

As regards specific forms of addiction care, in the Netherlands this includes help

kicking the habit, designated drug consumption facilities, voluntary or mandatory

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treatment, and inpatient or outpatient care. In the Netherlands, most people with a

drug problem are treated in outpatient addiction care.

Outpatient care involves intervention in acute problems, help kicking the habit,

improving the quality of people’s lives, helping people regulate their consumption and

avoid further damage to their health, reaching out to problem users who do not seek

help themselves (assertive outreach intervention), and preventive measures.

Inpatient care involves crisis care, detoxification programmes, and treatment in clinics,

therapeutic communities or wards in psychiatric hospitals. Inpatient care is more

intensive than outpatient care. It is geared towards preparing people for their return to

society.

Forms of addiction care:

From harm Reduction to abstinence based facilities

Ambulantory, semi-residential, residential care (stepped care)

Social addiction care

Private clinics

Christian addiction care

Self-help groups

Some recent developments:

Disappearance welfare state

Participation society

‘Ambulatorization’ (reduction of beds)

Dichotomy in specialized and general mental health care

Central role for the general practicioner

Greater use of one’s own social network

4. Concluding remarks

Treatment as part of rehabilitation. Dealing with the core issues. Facilitate integration

in society. Other parts are reintegration, prevention, social support and

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religion/spirituality in the framework of the renewing of moral consciousness. Drug

policy needs to be compassionate policy.

Rehabilitation is in almost all cases the proper thing to do. However, this does not

exclude punishment in some cases. For addiction, as we have seen, does not rule out

accountability. But even when incarceration is demanded, the focus should be as much

as possible on reintegration. For the government has an obligation to facilitate the

possibility of a good life and a good society. It has to contribute to the solving of

societal and social problems. Drug policy as part of government policies in general

cannot be separated from characteristic notions within a democratic society regarding

the summum bonum, the highest good. The possibility or impossibility of drug use and

addiction within a society should be seen within this framework and determines

whether interfering and intervening by the government is appropriate; and, if yes, to

what extent.

In many Western countries the ideas regarding drugs and drug use as well as the

government policy regarding them, have been highly stamped by the cultural

revolution of the sixties. This revolution meant a revaluation of many moral issues,

among which drugs and drug use. Up till that time, desires were subordinate to the

mind. Then, however, the highest good was sought in the satisfaction of the desires,

whatever they might be. The optimum satisfaction of these hedonistic desires would,

according to the 19th century British philosopher, political economist and civil servant

John Stuart Mill’s in his book ‘On Liberty’, result in happiness. Mill also indicated

that that a human being should live in accordance with his own inner unique identity,

in accordance with his so called ‘authenticity’. As far as I can see, hedonism and

authenticity are important factors in understanding what we are dealing with regarding

drugs and drug use.

In the present day liberal morality – with its emphasis on ‘freedom’ – individual

persons are supposed to give their own idiosyncratic meaning to their existence.

Whether a government is allowed to intervene here, is based on the justification

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principle and/or the harm principle. Non-interference by the government (non

paternalism) is often based on the so called neutrality of the government, and the

individual person as the center of all deliberations. However, already Mill in the 19th

century wrote about the possibility of intervention by the government, namely where

the freedom of one person brings harm to the freedom of the other. Where the harm

principle used to be only one of the principles regarding good and evil, today this

principle seems to have been elevated as being the most important principle of

morality. But what exactly constitutes harm is not so easy to define, including harm in

the framework of drug use. Governmental paternalism regarding drug use, i.e. a

restrictive drug policy, can quite well be defended. The dangers connected with drugs

and drug use are such, that restriction of autonomy of the individual has as purpose,

that he is better enabled to make healthy choices and thereby enlarge his future

autonomy and freedom. For freedom is not just freedom ‘from’ but also freedom ‘for’.

Ways out of drug abuse – rehabilitation instead of punishment, ask for accountability,

and making healthy choices possible. Asks for BPSS model. Only focusing on health

without taking into considerations that laws have been broken, and on the other hand

only focusing on punishment without taking into consideration the health aspects

won’t be helpful. Both, rehabilitation and punishment, need to be addressed under the

umbrella of a compassionate drug policy that also takes into account the existential

layer of the addiction problem.

I thank you for your attention.

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