ATTC Messenger August 2014: A Social Justice Lens for Addictions Practice

August 2014

Strengthening a Social Justice Lens for Addictions Practice:
Exploration, Reflections, Possibilities, and a Challenge to to Promote Recovery Among the Most Vulnerable

Laura Burney Nissen, PhD, LMSW, CADCIII
Dean and Professor
School of Social Work
Portland State University

Overview

Addiction is commonly conceptualized as a personal problem, a family problem, a neighborhood problem, a community problem, and even a social problem. But how might addiction be understood as a social justice problem?

Substance abuse problems, addictions, and addiction treatment and the related preparation of professionals to fill its treatment ranks exist within an ideological and political infrastructure. Issues of social justice are often conspicuously absent as a primary consideration of the experience of people seeking treatment (acknowledging the treatment gap that impacts some people more than others), for communities ravaged by addiction (acknowledging that some communities are affected more severely than others), or in the national discussion of addiction as a problem. And in this national discussion, addiction is viewed more as an individual—and sometimes family—problem, rather than as a social determinant of health, community safety, and public health.

This brief article suggests that there is a need for more creative, conscious, and robust evolution in our addictions treatment endeavors to increase positive outcomes equitably—and that addictions treatment practitioners have a key role to play in advancing the social justice challenges inherent to practice in this field.

Disparities in Addictions Treatment Access and Outcome

The literature clearly demonstrates that, due to a combination of long-standing structural and sociological factors, members of disadvantaged and marginalized communities fare less well in accessing addictions treatment, and being adequately supported to find long-term recovery. This is true despite the many advances that may be occurring with regard to the overall success of intervention proficiency (Austin & Wagner, 2010; Burns, 2009; Einstein, 2007; McGuire & Miranda, 2008; Morrow, Jamer & Weisser, 2011; Matthews & Lorah, 2005; Pickett & Wilkenson, 2010; Saloner & Le Cook, 2013; Weiner, Morrow & James, 2011).

Research has shown that the current body of evidence-based practices in behavioral health treatment have generally not successfully addressed the needs of diverse communities (McBeath, Briggs & Aisenberg, 2010; Aisenberg, 2008). Some progress is being made, however, among scholars that intend to intentionally evolve and adapt interventions to diverse communities (Bernal, Jimenez-Chafey & Rodriguez, 2009; Morales & Norcross, 2010). The federal infrastructure addressing this issue has even expanded, with SAMHSA’s creation of an Office of Behavioral Health Equity to take up the challenge of improving outcomes to diverse people served in behavioral health settings (http://beta.samhsa.gov/behavioral-health-equity). Despite these efforts, much more work needs to be done, and significant disparities persist.

Seeing the Connections Between Addiction and Social Justice

To effectively help advance the cause of social justice, addiction professionals need a thorough grounding in the conceptual and practical aspects of defining social justice so they can begin to “see through a social justice lens,” in addition to their standard clinical practice lens.

For purposes of this overview, social justice should be conceptualized as a state in which equity, fairness, opportunity and success for all diverse members of a society are commonplace and expected, in which there is acknowledgement that personal and structural success and struggles in a society are intertwined, and that inequities of the past are acknowledged and redressed (Barker, 2003). Closely associated with the profession of social work (Finn & Jacobsen, 2008), social justice practice also aligns with public health’s “social determinants of health” framework, which asserts that health outcomes are in fact, not generally random, but closely associated with economic and social drivers (http://www.cdc.gov/socialdeterminants/).

Conceptual Cornerstones

A couple of additional cornerstone concepts provide essential assistance in further developing social justice sensibility:

Intersectionality and Anti-Essentialism: Intersectionality is a concept that encourages great care and restraint in generalizing anyone’s experience to a uni-dimensional label or identity (e.g., the universalizing of such descriptors as “African-American” or “Female” or “Disabled” perspectives); rather, it acknowledges that every individual is comprised of a complex array of inter-related identities, experiences, and perspectives, all with varying degrees of privilege (Grillo, 1995; Hulko, 2009). Intersectionality theory suggests that frequently, oppressions and privileges cluster together and create constellations of either opportunity or the lack of it. These categories cannot be grouped in a uniform fashion and, therefore, practice with diverse people should be led by inquiry and partnerships with individuals and communities, and not by assumptions. Failure to do this results in deeper levels of stereotyping and objectifying, even as such efforts are often intended to promote diversity.

Oppression and Anti-Oppressive Practice (AOP): When social injustice becomes the norm, then oppression becomes commonplace and the need for “anti-oppressive practice” (AOP) becomes more important. AOP is a set of ideas and practices advancing in a number of professions (social work has been at the forefront) to prepare professionals to engage in practices that advance social justice and address inequities in all their forms. Advanced by Young (2010), a clear definition of the “faces” of oppression includes features such as exploitation, marginalization, powerlessness, cultural imperialism, and violence (pp. 35–44).

AOP seeks to prepare practitioners to use a social justice lens at all times, to observe and interact with individuals, families, and neighborhoods at the same time they are considering and interacting with larger structural forces that create, perpetuate, and complicate peoples’ opportunities for success and well-being (Baines, 2007). It also includes a need for those in practice to carefully and conscientiously consider their own identities, positions of privilege, and experiences with oppression to avoid the common pitfalls of becoming part of the social problem rather than of the solution (Heron, 2005).

Exploring Levels of Practice
With social justice-anchored questions for those in addictions practice

To bring practicality to this discussion, this article concludes with some challenging questions for addictions professionals to themselves and their administrative leadership. Asking, and courageously answering, such questions might significantly advance our overall capacity to be more responsive, more equity-centered, and ultimately, more effective. Early explorations into the intersections of social justice and addictions practice have shown promise (Nissen & Curry-Stevens, 2012; Curry-Stevens & Nissen, 2011) but additional efforts to explore the application of social justice-anchored and informed interventions need to be made.

A social justice lens for work with individuals/families

• To what degree are our efforts with individuals and families connected to the diverse challenges they face in the real worlds they inhabit? Are there disparities in who or how treatment need is acknowledged and accessed?
• Are such issues as poverty, houselessness, other health challenges, and other human rights concerns intersecting with the need for addictions treatment, and how well do we attend to these challenges?
• Do we acknowledge both diversity, and the diversity within diverse groups, in the way that we offer, deliver, and create ongoing recovery supports?
• Is client voice and a true sense of empowerment and strengths perspective active, visible, and embedded into the way that services are delivered? How is client voice and authority apparent?

 A social justice lens for work with communities

• To what degree do we acknowledge (and participate in addressing) the economic and health disparities across the board that play a role in the communities in which addictions are most apparent?
• Does the community in which treatment is being offered have a voice in the design, function, operation, and overall measurement of success of the program?
• Are community’s efforts to resolve addiction problems heard, respected, and when possible, partnered with to create networks of possibility rather than contribute to systems fragmentation?

 A social justice lens for work with organizations

• To what degree do our treatment organizations challenge themselves to review, consider, and resolve diversity-related disparities in treatment access and outcomes?
• Do our organizational missions reflect more than an individualistic notion of addiction and recovery, but also focus on social and social justice levers for action, engagement and improvement?
• Do our treatment organizations create meaningful learning opportunities for treatment practitioners to explore their own biases, stereotypes, and blind spots regarding the causes and progression of addictive behavior, as well as the possibilities of success for recovery among diverse populations?
• Do our treatment organizations recruit, hire, and promote diverse staff to reflect the diversity of the communities in which they provide services?
• Do our governing structures (Boards of Directors, etc.) have more than tokenistic representation of diverse communities?

 A social justice lens for work with policy

• To what degree do we actively participate in efforts to better attend to the policy drivers that limit and/or control access and/or availability of treatment for vulnerable and marginalized communities? (Who gets access to the “cutting edge” treatments and why? How long do people have to wait for the type of treatment that best meets their needs?)
• Do we partner with communities to build better prevention and early intervention opportunities, rather than default to services closely aligned with and/or embedded into juvenile/criminal justice programs as the only service option?
• How can we better focus on community wellness as a policy driver for greater economic justice, school success, health, and overall well-being indicators for vulnerable populations?

The Recovery Movement and Related Addictions Treatment Partnerships

In closing, it is relevant to mention the promise and possibility inherent in one of the most important advances in the last 20 years across the addictions treatment field (Davidson, Tondora, O’Connell, Kirk, Rockholz & Evans, 2007; Laudet & White, 2008; Jacobsen & Farah, 2012): the recovery movement (often referred to as a “recovery oriented system of care”). As with the goals of the newly enacted federal Affordable Care Act (ACA), the recovery-oriented system of care movement holds the very real goal of acknowledging that acute care for substance use disorders is but one aspect of successful recovery, and that a network of community-embedded, community-owned, and community-identified resources, both known and useful to those in recovery, is essential to long-lasting recovery. (http://www.williamwhitepapers.com/pr/CSAT%20ROSC%20Definition.pdf).

It would seem clear that such recovery-oriented support networks cannot exist successfully where injustice and oppression are not simultaneously addressed, and that community wellbeing takes greater focus, yet that is not yet explicit in the discourse of the movement. In moving forward, this new paradigm—building community infrastructure to simultaneously prevent addiction while promoting recovery— can become a strong scaffolding for social justice as well as for long-term successful recovery. Whether that occurs will be left to the activists, practitioners, scholars, community members, persons in recovery and leaders themselves to determine.

Note: Thanks to Dr. Charlotte Goodluck and Lisa Hawash for comments on this article.