Social Lives
Author: A. Jamie Saris, Associate Professor in the Department of Anthropology and Assisting Living and Learning (ALL) Institute member, Maynooth University
A former student of mine (who has struggled with opiate use and misuse during much of their adult life) recently contacted me for a reference. As I have worked ethnographically with heroin users for many years, and I have written extensively on “addiction” as a concept, I have occasionally been approached by students who have experienced some of the situations that I have written about – from the regulation of time imposed by regular ingestion of a Heroin substitute through the experience of regular use of illegal drugs (especially Heroin) spiralling out of control into increasing risk-taking and subsequent legal jeopardy and health dangers. Thus, over the years, this student and I have had several conversations around their ideas of “addiction” and “recovery” in relation to my work and theorizing.
As part of asking for the reference, this student also caught me up on their life, which is now opiate free, and, seemingly (and happily), much improved: they no longer use methadone or heroin, are in a satisfying relationship, and they convey the sentiment that they are glad to be where they are. Alongside conveying this welcome news, they also challenged a term that I (and many other researchers and clinicians) have used in our writing – “functioning”.
I know we talked [before] about ‘functioning addicts’ – but really, ‘functioning addicts’ – that’s only to the outsider, the addict themselves aren’t functioning, not correctly mentally, physically, or in anyway.
No good ethnographer has an issue with conceding some space in expertise to their interlocuters with life experience of the issues under discussion. This critique of “functioning”, however, has been nagging me for the past several weeks, as it is at the heart of important theoretical debates in both Anthropology and Medicine. The “functionalist bias” in Anthropology, for example, is widespread and oft-critiqued. The classic anthropological trope of finding a purpose for nearly any cultural “trait” can, arguably, too-readily reframe nearly any behaviour or custom in terms of “function”, thus seeming pathology can almost always be translated into ideas like “expressing local meanings” or “claiming local agency”. Robert Edgerton in Sick Societies mocks this attitude and then proceeds to develop several cases where different social groups literally destroyed themselves in quite bizarre ways, precisely as a challenge to what he considers this dangerously naïve way of framing human behaviour.
But, medicine also relies heavily on an understanding of “function”, as in “functional restoration”. The grandaddy of this model was, of course, the discovery of insulin, a then near-miracle therapeutic that could extend the life of someone with Diabetes, eventually to almost the expectations on their actuarial tables. Thus, a disease that for much of human history was a slow-motion, generally very messy, death sentence transformed into a manageable chronic condition. It is a testament to the success of this discovery in what we might call the “popular medical imaginary”, that, while “functional restoration” is not widely used outside of Medicine, the ability to change a serious disease, hitherto leading to severe disability or death, into a manageable chronic condition is still widely modelled on the success of insulin for treating Diabetes. Everything from the introduction of antipsychotics for major mental illnesses in the 1950s through the roll-out of Highly-Active Antiretroviral Therapy [HAART] for HIV in the 1990s, was analogized on insulin’s perceived success, allowing these conditions to become “something like Diabetes”.
Not surprisingly, “functional restoration” was also the model applied to the search for opiate substitutes when they were trialled for heroin dependency. Methadone Maintenance Therapy [MMT], for example, was pioneered by Vincent Dole in the 1950s and 60s with precisely this model in mind. Dole was himself an Endocrinologist, and along with his colleague, Marie Nyswander, trialled Methadone expecting it to work “like Insulin for Diabetes” in the lives of addicts, allowing such people to resume a “normal life” because the “metabolic lesion”, posited as the source of the addict’s cravings, was being chemically worked around. “Function” was, thus, going to be restored, but only though the regular ingestion of another substance.
From the beginning, Methadone had its critics, from a genuine uncertainty as to the length of time required to stay on the drug (Dole argued that it would be life-long) through both recipients and taxpayers complaining about (what one of my regular informants observed to me some years ago), “Just replacing one addiction with another”. In retrospect, it was also the then-latest means of managing a strange kind of therapeutic citizenship, addicts, a gens connected not by shared blood, but by shared blood pollutants, or by a shared flawed capacities, such as a tendency to be an ‘addictive personality’. Thus, before Methadone, there had been other “moral” technologies, such as recovery groups, aimed, at various kinds of addicts – alcoholics, drug addicts, sex addicts, gambling addicts, and later, people with eating disorders, people with anorexia, eventually even embracing such exotic passions as the internet.
William Griffith Williams (better known to the world as Bill W), the founder of Alcoholics Anonymous [AA] (which in turn has served as the model for nearly all other Recovery Movements) expressly recognized this aspect of sharing in the experience of bondage to a substance as defining a group. He reframed such membership, however, as a means of detaching oneself from an individual failing to control a recursive and disabling desire, through being inducted into an more enabling community, marked by regular meetings and distinctive repetitive rituals. In such rituals, one can hear an only half-secularized echo of the powerful words attributed to Paul in Galatians 3:28, “There is neither Jew nor Greek, there is neither bond nor free, there is neither male nor female: for ye are all one in Christ Jesus” (KJV) in the well-known public presentation of self in an AA meeting – “Hi my name is ___, and I am an alcoholic (or ‘fill in the blank’).” This ritual, though, is but a pathway towards a curious subjectivity – (re)gaining the ability to make decisions in one’s life by admitting that one does not have control over it. It is a sort of spiritual reflection of the physical use, a pharmaceutical work-around (taken daily) to repair the compulsion to repeat the same activity (very often the ingestion of another drug). Both techniques measure their success by their ability to “restore” a life back to an “addict”.
So, are “functional restoration” and “recovery” the same thing, or very different or, perhaps, similar ideas cast in wildly varying registers? There is no easy answer to this question. For decades, “addiction” has made uncomfortable bedfellows of a saccharin spirituality and a bitter materialist science. Proponents of both the physical and spiritual toolkits for repairing the addicted subject have written volumes about this relationship, generally with a strong bias towards the claim that any state of seeming recovery, while always precarious, is even more fraught outside of their preferred methodology.
In the end, my former student now claims to be more than “functioning”, living well in the absence of heroin, methadone or a communal production of “recovery”. In an earlier idiom, popular before the Triumph of the Therapeutic explored by Reiff, we might say they are now more “comfortable in their own skin”. Addiction, after years of infiltrating their lifeworld and identity (addict), has been replaced with another, happier version of themselves, away from both pharmacological substitutes and the moral frame work of “Recovery”. Perhaps, if this person had been asked earlier about their own sense of some of the central concepts explored in this paper, then different therapeutic pathways, more focussed on endpoints, rather than means, might have emerged. Such a treatment paradigm, however, would be very different to what we have now. It would begin by taking drug-users (indeed all “addicts”) seriously as one source of expertise in their own lives, and it would require co-designing services after consulting such expertise. Necessarily, it would cede some control in defining such key terms as “function”, “restoration” and “recovery”. Finally, its understanding of “success” would have to take seriously the feedback of the participants, especially if and how they found such interventions meaningful and useful in their own lives. Both the material and spiritual engineers building bridges leading away from “addiction” seem as yet unwilling to take up such inputs in their calculating solutions to the problem of recursive and disabling appetites.