The blame game doesn’t work on an individual level, but it’s an essential ingredient for improving public health



Photos: Wikimedia Commons

Like ice cubes into a glass, two emails by two of my favorite bloggers clinked into my inbox almost simultaneously.  Both about accountability.  I almost felt privy to an argument between C. Scott McMillin and William White.  Or at least at seemed that way at first.

Who is responsible when addiction treatment doesn’t seem to work?” each blogger asked.  As you’ll see, McMillin’s piece zeroes in on the personal responsibility of the user whereas White wants to talk about the responsibility of the treatment system as a whole.

I took the liberty of cutting and pasting from their individual posts to hold their ideas side-by-side. [emphasis added]

C. Scott McMillin (Whose Fault Is It, Anyway?)

  •  To use or drink is a personal decision. It’s very difficult for anyone else to prevent an addict from returning to use if he decides to.
  • There’s the nature of addiction, which is to return to use despite the adverse consequences that follow. You could argue (and many have) that relapse is just a demonstration by the disease of its continuing influence.
  • To quote George Vaillant in 1988, after reviewing the long-term findings on addiction recovery: “…to a remarkable degree, relapse to drugs is independent of conscious freewill and motivation.”
  • So why play the blame game? I suspect it’s a way of avoiding the painful reality that we’re not really in control of the outcome. Not the parent, not the therapist. It makes us uncomfortable to acknowledge that degree of helplessness. Easier to pretend that somebody else could have done something different and saved the day.
  • It may turn out that young Alfred Addict may someday look back on this relapse not as a tragedy but as an important step on the road to successful recovery.

William White (Personal Failure or System Failure?)

  • I have advocated a stance of total personal responsibility:  Recovery by any means necessary under any circumstances. That position does not alleviate the accountabilities of addiction treatment as a system of care.
  • When symptoms continue or worsen following addiction treatment, it is the patient who is blamed and often punished.
  •  If we are going to participate in giving people a chance, then we need to make sure it is a real chance and not a set-up for what is ultimately more a system failure than a personal failure.
  • We are routinely placing individuals with high problem severity, complexity and chronicity in treatment modalities whose low intensity and short duration of service offer little realistic hope for successful post-treatment recovery maintenance.
  • Self-inventory, inventory disclosure and making amends have been among the essential steps of recovery within AA, NA and other 12-Step groups.  Perhaps it is time for leaders of addiction treatment to conduct a similar series of steps.

Seems like they disagree, right?  And for me, the synchronicity of their posts, clink-clank, reinforced that idea.  But on further reflection, I don’t think they’re arguing.  I think they’re talking about accountability using two distinctly different paradigms.

In fact, I think looking at these posts together illustrates the difference between an individual health paradigm and a public health paradigm by showing us that one particular approach doesn’t necessary translate across the two.  That is, held next to each other, these posts demonstrate that the practice of finger pointing can hinder good health outcomes on an individual basis, but is an essential ingredient for improving public health.

McMillin is looking at an individual health outcome and, certainly, his point is well taken. It’s easy to picture 16-year old “Alfred Addict” encircled by frowning grownups, a feeling of stalemate in the air.  In that case, the “blame game” may absolutely emerge from a feeling of helplessness.  And the interpersonal dynamics that emerge from that “game” could delay or complicate Alfred’s recovery process. On an individual level, dissecting causal and modifying factors may not have much value.

White, on the other hand, is talking about lots of people and the systems that they live in, which is a public health view of the world.  This is where the “blame game” gets productive.

Complex, age-old problems like substance use disorders have a constellation of causes.  Improving public health by reducing substance-related harms calls for widespread self-inventory, brainstorming, and collaboration.  And when we examine the world through a public health lens–when we step back and look at a bigger picture–no one can claim “helplessness” because there’s so much to be done.

We can advocate for health systems that actually address the chronic nature of addiction, as Bill White has done so tirelessly.  Or talk openly about our personal recovery process, like 29-year old Greg Williams who directed The Anonymous People (go see it!).  We can defend the civil rights of those with histories of addiction, like the Legal Action Center, or implement Screening, Brief Intervention and Referral to Treatment (SBIRT) in new, innovative settings, like so many of the folks we have the privilege of working with as the National SBIRT ATTC.  Or we can talk about a child’s overdose in the hopes of saving someone else’s child, like these people, and this person, and many others.

individual community and society influences affecting drug use

Complex, age-old problems like substance use disorders have a constellation of causes

A public health paradigm presumes that, in McMillin’s words, “we’re not really in control of the outcome” in any one person’s life, but that we’re obliged–we’re eager–to address system failures that produce undesirable, often tragic, results.  And like a self-inventory, the work never ends.

British systems scientist Dr. Geoffrey Vickers said it quite well: “The goals of public health consist of successive redefinitions of the unacceptable.”  What an ambitious and, ultimately, optimistic idea.  That we should always feel like we have a long way to go.

Recommended Resource

Addiction Advocacy 101 infographic by NAADAC