Abstract
In light of the current spike in opioid addiction in upper middle-class white populations, we examine addiction treatment discourses on the webpages of public methadone clinics and private rehabilitation facilities through a critical theoretical lens. While both discourses exercise social control over opioid-addicted clients by regulating their everyday practices, we find classed differences in these discourses when they are aimed at differently socially located populations. Private treatment discourses trust clients to be led to a state of self-governance through a holistic transformation of ‘mind, body, and spirit’, while public clinics’ websites frame patients as unruly bodies that must be chemically rendered docile through medication before they can return to everyday life.
Introduction
As horror stories, cautionary tales, and calls to policy changes about addiction flood news media and popular discourse, addiction treatment rises to the forefront of focus for medical professionals, laypeople, and researchers alike. Drawing from the work of Michel Foucault and his concepts of normalization and governmentality, we argue that ‘addicts’ are subject to the disciplinary gazes of both the criminal justice system and medicine and as such, must constantly self-police their behaviors and desires. Addicted subjects are governed by medical, psychiatric, and legal discourses. They are framed as both precariously ill and morally responsible for their actions before, during, and after recovery. Addiction to opioid-type substances like heroin is typically associated with poverty and racial minority status, and the raced and classed undertones of addiction discourse for these populations are well documented (e.g. Acker, 2002; Room, 2003). However, rates of opioid addiction and treatment are rising among higher socioeconomic status whites, and parallel differences in how addiction treatment discourses operate are emerging. We explore how these differently socially located populations are subject to regulation of behavior, and from whom this regulation is expected to come.
We conducted a content analysis of website data from 40 addiction treatment centers and facilities in New York, dividing our attention between public clinics and private rehabilitation services. Despite different approaches to framing the individual seeking treatment, both private and public treatment centers’ websites exposed explicit or implicit emphases on normalization, either through self-governance or via the effect of docilizing drugs. We present our theoretical analysis alongside empirical findings to argue that addiction treatment discourse seeks to return addicted persons to a state of independence, in which recovery from addiction includes normalized patterns of behavior. However, this discourse is mobilized differently along class lines, and ‘independence’ takes on different meanings for differently socially located groups.
Literature review and theoretical framework
The historically shifting definition of addiction reflects an ongoing power struggle between medicine, law enforcement, social science, and politics to control how addicts are defined and treated throughout the 19th and 20th centuries (Courtwright, 2010; Hickman, 2004). The adoption of a disease model of addiction epitomises the medicalization of deviance (Conrad, 2010) as medical practitioners attempt to regulate and transform the bodies and subjectivities of their patients. Through the standardization of minute physical practices of everyday life and the reformation of thought processes regarding one’s self and behavior, powerful medical discourses inscribe themselves on the bodies and subjectivities of ‘addicts’. Though it follows from this theoretical framework that all people who seek treatment from addiction are subject to this form of social control, race, class, and access to health services impact the deployment of these discourses.
Neoliberalism and late modernity complicate a full acceptance of addiction as a disease outside of the control of the individual. Addiction, particularly in the western world, is constructed within a society that stresses individualism, self-control, and responsibility, and which has historically connected individual self-governance with moral goodness (Room, 2003; Weber, 1930). To be a good citizen in a neoliberal society is to attain individual achievement through hard work, demonstrating one’s goodness as measured through financial independence (Wacquant, 2009). Independence is directly threatened by substance abuse because of its threat to a person’s ability to ‘carry out major obligations at work, school, or home’ (American Psychiatric Association, 2013). This inability to fulfill responsibilities renders individuals dependent on others, including family, friends, and/or the state for assistance. The goal of addiction treatment, in this view, is to return people who are dependent on substances to a state of independence. However, who can be expected to achieve independence—from drugs, and from the state—differs along class lines, which transforms the ways in which addiction discourse is deployed for differently socially located populations. In order to examine these disparities in addiction treatment discourse, we frame this discourse as the proposal of different techniques of normalization.
In the context of our analysis, normalization describes the mechanisms or processes that mental health professionals and medical discourses assert are best for people undergoing addiction treatment. Normalization refers to the exercise of power to regulate the minute actions of individuals and populations according to a standard of conduct. This process disciplines and regulates both individual bodies and populations (Foucault, 2003b). Medical, psychiatric, and legal discourses converge to exercise power over the bodies and subjectivities of ‘addicts’, with the intent of normalizing their behavior in recovery toward practices that impede repeat substance abuse. These processes of normalization are different for differently socially located people, and not only allow but reinforce social and individual differences: ‘[i]n a sense, the power of normalization imposes homogeneity; but it individualizes by making it possible to measure gaps, to determine levels, to fix specialties and to render the differences useful by fitting them one to another’ (Foucault, 1977: 184). In that sense, processes of normalization reflect and reconstruct hierarchical differences in populations by concentrating different mechanisms of normalization, even while they promote sameness. We seek to explore how mechanisms of normalization are mobilized differently across differently socially located populations while simultaneously promoting a dominant sameness. The goal of normalization is to return unruly bodies to a state of docility. How is normalization in the form of addiction treatment meant to return different types of addicted persons to docility (non-use)? How is this docility expected to be maintained long-term?
The answer to these questions lies in whether members of that particular population are seen as dangerous, whether they are seen as having a mental illness, and whether they can be treated or cured. Foucault (2003a: 25) describes these processes in his discussion of psychiatry intervening in legal processes of punishment. Penalization for delinquent behavior, in the case of those who can be diagnosed with an illness that caused the delinquency, are not just sanctioned by law but subject to ‘a technique that consists in singling out dangerous individuals and […] taking responsibility for those who are accessible to penal sanction in order to cure them or reform them’. All people who are subject to addiction treatment undergo these ‘reforming’ techniques of normalization. However, how this normalization is mobilized, and whether it is directed more strongly at regulating bodies versus subjectivities, varies based on the perceived capabilities of different groups to return to a state of unassisted self-governance. We turn to a discussion of governmentality to explore this key difference in techniques of normalization in addiction discourse.
Governmentality is a process which places populations and individuals in positions to be governed by a multitude of powerful forces, including authorities, institutions, and dominant discourses (Foucault, 1997). Governmentality refers to ‘an activity that undertakes to conduct individuals throughout their lives by placing them under the authority of a guide responsible for what they do and for what happens to them’ (quoted in Rose et al., 2006: 83). Under this framework, an individual’s choice to recover, particularly in the context of an ‘illness’ that typically includes multiple instances of relapse, necessitates a large amount of minute self-policing of behavior. This self-policing takes place in addition to the regulation of bodies and subjectivities that occurs at the hands of medical professionals within the treatment context (Carton, 2014; Fischer et al., 2004). While all people who seek treatment for opioid addiction are expected to police their own behaviour, the form that self-policing takes differs for upper middle-class white populations and for lower-class racial minority populations (e.g. Conrad and Mackie, 2011; Fox, 1999; Hansen and Roberts, 2012; Wells et al., 2001). More simply, all people who seek addiction treatment are socially controlled (Netherland, 2011). However, the means of social control and who is expected to implement it varies by race and class (e.g. Hansen and Roberts, 2012; McKim, 2014).
Illicit drug use is a crime, yet not all those who use drugs are managed in the criminal justice system. Depending on their race and class, individuals who are arrested for drug possession may be sent into coerced treatment in lieu of jail (Alexander, 2012; Tiger, 2011). Those in the criminal justice system are much more likely to be refered to public methadone clinics rather than private treatment centers, which cater primarily for people who seek treatment without a court order (Bourgois, 2000; Hansen and Roberts, 2012; Wheeler and Nahra, 2000). Further distinctions exist. People who seek treatment for heroin addiction in methadone-maintenance programs are often considered as lazy, selfish, criminals, for instance, while those who seek help from AA for alcoholism are seeking redemption (Fox, 1999). These different perceptions come not only from outsiders looking into recovery movements, but are also perpetuated by members of recovery groups themselves (Travis, 2009). This double standard mirrors class differences in how parents and their children navigate institutions like the educational system (Lareau, 2011) as well as the harsher punishments for and lower expectations of socioeconomically disadvantaged groups that are well documented in the criminological literature (e.g. Chambliss, 1973).
Treatment for heroin addiction in methadone clinics has been described as harsh and hostile, punishing those who violated social norms while attempting to regulate their nonproductive and disruptive bodies (Bourgois, 2000; Keane, 2008). Previous scholarship has also demonstrated how the depiction of addiction as a neurobiological disease masks the power relations at work in disciplining disorderly bodies and subjectivities, using essentialist logic to reinforce racist and classist ideas about criminal drug users and those diagnosed with mental illness (Bennett, 2011; Gowan and Whetstone, 2012; Metzl, 2010). We seek to expand this argument by interrogating whether treatment discourses aimed at specific clientele maintain raced and classed narratives about the criminality or lack thereof of different groups. We focus on class, considering our data cannot as adequately address racial disparities, though note that race and class are typically intertwined (e.g. Frohmann, 1997), especially in mainstream addiction discourse.
We contextualize our discussion of addiction treatment within a critical addictions framework that rests on several basic principles: addictions are contextual problems that are historically and culturally specific, are interwoven with complex social forces and influences, and interact with different groups of people at various levels of the social hierarchy differently (Reinarman and Granfield, 2015). Paying close attention to the differences in addiction treatment discourses across social groups is essential because drug use is more heavily criminalized for poor and marginalized groups than for white, upper middle-class citizens (Conrad and Mackie, 2011; Fox, 1999; Hansen and Roberts, 2012; Wells et al., 2001) for whom rates of opioid addiction and treatment are currently spiking (Centers for Disease Control and Prevention, 2010; International Narcotics Control Board, 2014). An interrogation of how different groups of people addicted to opioids are treated in addiction discourse is vital to understanding how social location influences the conceptualization of addiction and the criminalization of drug use.
Methods
We collected our data from a list of addiction treatment centers, services, and facilities in New York State provided by the Substance Abuse and Mental Health Administration (SAMHSA), which allowed us to identify a split between public clinics and private, often residential, treatment centers. We collected data from treatment center websites, including written information on home pages or links to the addiction-specific aspects of the services, as well as photographs displayed on these pages that depicted treatment-related activities (therapy groups, doctors examining patients, etc.). Using data from treatment center websites reveals how different types of centers present themselves to potential and current clients, and also allows researchers to analyze content that clients themselves see, interpret, and make decisions from and about when considering addiction treatment.
We collected data from 20 different private facilities’ websites and 20 public addiction service websites. Each dataset was initially open coded for general themes, recurring phrases, and discussions of types of addiction treatment approaches (see Table 1). Open coding allowed us to develop an understanding of all emergent themes in the data, preventing bias that can emerge when researchers approach new data with preexisting, structured coding schemes in place. We then coded a second time using specific themes developed from the open coding before reviewing both datasets and coding for accuracy, consistency, and validity. The codes were then quantified in tables for public, private, and aggregate totals to guide qualitative analysis of the most salient quotations and excerpts from the content (see Table 2).
Addiction treatment website coding scheme.
Addiction treatment website code totals.
We use data from New York because of the diversity of services in the state—ranging from metropolitan Manhattan to large suburbs to small, rural areas—and New York’s high population and corresponding large amount of treatment centers. New York has seen a substantial increase in heroin use and treatment, with heroin treatment admissions in Upstate New York rising by 115 percent and admissions in Long Island increasing 116 percent since 2004 (NYS Office of the Governor, 2015). The state’s dozens of methadone clinics and numerous private rehabilitation centers allowed us to collect sizeable datasets containing content from both types of treatment services’ websites while containing our analysis to one state, thus reducing the potential for validity issues that comparing between and across states with different drug laws could create. While we anticipate that treatment centers and services vary by state, the data from New York suggest a notable difference between public and private services’ discourses that reflects larger patterns found in the United States (Roman et al., 2006; Wheeler and Nahra, 2000). Race and class disparities in treatment access and discourses also persist throughout the country (D’Aunno and Pollack, 2002; Wells et al., 2001). As such, the New York treatment center data we collected and analyzed are arguably representative of broader differences between types of addiction service discourses across the country.
Objectification vs holism: Language, discourse, and power
Both public and private addiction treatment centers’ websites emphasized the ‘disease concept’ of addiction. This emphasis explicitly endorses medicalized notions of drug and alcohol habits. However, this medicalized understanding of addiction was used to frame clients and treatment in considerably different ways: they are either objects to be governed or subjects capable of self-governance. For example, methadone maintenance and public hospital detox is lifesaving, while private residential rehab is life changing. ‘Lifesaving’ invokes images of addicted bodies, while ‘life changing’ depicts subjects actively engaged in transforming themselves. Methadone clinics treat the drug-dependent, while high-end treatment facilities concern themselves with the mind, body, and spirit of struggling individuals.
Medical and legal discourses permeate the language of both public and private addiction treatment services. However there is a clear divide between those which treat clients as objects of medical and legal intervention and others who view them as subjects in need of tools to boost their recovery. Public treatment centers and methadone clinics’ websites employed objectifying language, while private facilities more often framed clients as multifaceted subjects whose addiction requires holistic approaches. One public hospital, located in the eastern region of the state, advertises on its website that: The primary objective of treatment is to help persons suffering from these illnesses to achieve and maintain abstinence from alcohol and all illicit and/or medically unauthorized drugs. The goal is to assist alcoholics and other chemically dependent persons in learning the attitudes, skills, abilities and information necessary for successful and fulfilling recoveries.
This description presents clients as ‘alcoholics’ and ‘other chemically dependent persons’, placing emphasis on the pressing medical need to treat the illness of addiction.
The theme of objectification through language arose 35 times in data from public treatment services’ websites and only once in the private treatment data. The impersonal description of what and how clients will learn about addiction and recovery, coupled with phrasing that suggests clients are the objects of medical treatment rather than agentive subjects, contrasts greatly with how a private residential rehab in Upstate New York presents its ‘goals’ for clients: To assist individuals and families affected by the disease of addiction and to enhance their lives through a therapeutic process with quality care, professionalism, compassion and dignity. Understanding alcohol and drug addiction, its many manifestations, and its effects on the mind, body and spirit, is essential to finding recovery.
In contrast to the treatment goals of the public hospital, the private residential rehab service conceptualizes clients as ‘individuals and families’ who deserve ‘compassion and dignity’ through a focus on ‘mind, body, and spirit’. This holistic way of understanding clients as subjects was a clear theme in the all but one of the private treatment centers we examined, despite emerging only twice on the public clinic websites analyzed. In contrast, the objectification of methadone clinic clients as mere bodies suggests that they are subjects that need to be governed long-term by others, either by treatment facilities, the state, or chemically. In private centers, treating clients as people implies that they will be able to return to independence, regulating themselves through self-knowledge.
Holism assumes that clients have supportive relationships with family and other significant others. For example, one private treatment center claimed: ‘addiction is an illness that affects the mind, body and spirit of the addicted person and those close to them’ (emphasis added), while another emphasized ‘a holistic approach addressing the psychological and spiritual needs of the client, their family, and significant others throughout the recovery process’ (emphasis added). Clients of private rehabilitation centers are expected to rely on pre-existing social capital as well as the financial capital required to afford private care.
While family members and significant others were mentioned in the public center data, there were fewer occurrences of the theme than in the private center data (20 mentions as opposed to 36). Further, discussions of family in the public data largely understood family members as clients’ pathways to treatment who need information about their loved one’s addiction, rather than incorporating family members as a central part of treatment. If anything, family members are seen as contributing factors to addiction in public center treatment discourse. One public clinic’s home page stated, ‘[a]ddiction-trained social workers work with patients to assess family difficulties and housing needs, so that patients are discharged to the most therapeutic environment possible’, an environment which may well be away from detrimental relationships and ‘family dysfunction’. Another public clinic’s website claimed that patients who engage fully in recovery may ‘encourage their family members to follow their example’, implying that family members, rather than being a form of supportive social capital, may be addicts themselves who could benefit from witnessing successful treatment. Such an assumption necessarily draws from class-based stereotypes, reinforcing notions that socioeconomically disadvantaged families are dysfunctional, addicted, and unhealthy.
When discussing criminality in reference to drug use, driving while intoxicated, and/or other legal troubles arising from clients’ addictions, public and private treatment centers once again framed ther clients and their entanglements with the law differently. While public services assumed criminality to be part of their clients’ make-up, private treatment deflects attention from it, protecting clients whose future, recovered self reflects their being. In one public hospital in Western New York for instance, clients were referred to as ‘defendants’: ‘[i]n conjunction with drug courts, we offer assessment, treatment, and referrals to defendants whose arrest histories include alcohol or drug-related offenses.’ Another public treatment service, which primarily focused on offering methadone maintenance treatment to those in the New York City area, illustrated addiction and youth as a problem of criminality: To reach adolescents, we have increased our focus on preventative care to reduce recidivism […] With juveniles as young as nine and up to 20 detained in New York City juvenile detention centers, there is a broad swath of care required to teach them how to manage their mental health symptoms, their behavior, their relationships and their ability to function academically, socially and recreationally.
In this language of ‘recidivism’, the references to current and potential young clients as ‘juveniles’ and the observation that ‘there is a broad swath of care required’ to manage and neutralize the risk of incarceration, this service’s website expects that a move toward a future of independence and non-interaction with the state is less likely. These addicts are not just sick, but also entangled in the criminal justice system. Some private treatment facilities recognized that clients often face legal problems, yet tended to downplay their criminality. One residential rehabilitation program offers clients: ‘cooperation in obtaining appropriate legal representation from private attorneys or legal aide, transportation to court appearances and assistance in responding to subpoenas and warrants’. Another private treatment center for young people, based in New York City, notes that it: ‘does extensive work in court advocacy, giving many young people an alternative to incarceration. We are committed to clearing any obstacles that would stand in the way of a member’s rehabilitation.’
Private addiction treatment discourses acknowledge clients’ potential legal troubles, but do so by promising to assist clients with their cases in a professional manner or by providing clients alternatives to the criminal justice system—a life away from reliance on governance imposed by the state—through addiction treatment. The words ‘cooperation’, ‘appropriate’, and ‘private’ greatly contrast with public services’ discussion of working with clients who have criminal charges. ‘Advocacy’ and ‘clearing any obstacles’ implies an understanding of clients as individuals who will be able to lead independent lives that will not require future state intervention to regulate behavior. The use of these euphemisms obscures the seriousness of criminal charges and redirects focus away from clients’ past criminal behavior and toward the importance of returning to a normal life.
Neoliberalism and cultivating (in)dependence
Whether the individuals in treatment are humanized or objectified, all recovery discourse in our datasets emphasised individualized treatment plans and returning clients to full citizenship. Under neoliberalism, all people are individuals and need to be independent in order to be full members of society, but what those individuals look like and how well they are able to attain a state of economic and personal independence varies widely based on social location. While our data did not produce large quantitative differences in individualism (39 instances in the public dataset compared to 42 in the private dataset), the content of these instances is remarkably different in substance. On one side, according to website content, we found that private rehabilitation facilities cater to clients who lead complex inner lives and seek to return to meaningful, fulfilling careers. On the other, we found methadone clinics to regard clients as drug-dependent bodies that require individualized medication for detoxification and potentially long-term chemical governance.
One private treatment center’s top priority was to ‘identify goals and milestones that are meaningful and purposeful to you’ (emphasis added), speaking directly to the client as agentive subject and consumer, with the implication of partnership between treatment provider and client in setting recovery goals. Another private residential facility assured future clients that they are given treatment that is tailor-made to them, not just physically, but in regard to the whole person: We start with a complete physical and psychological evaluation which helps our clinicians develop an individualized treatment plan—custom made just for you. Our staff-to-resident ration of 3-to-1 provides the best opportunity for each person to receive personalized attention and care every day.
This type of language engages potential consumers on a level that acknowledges their status; their individuality is complex, and they deserve ‘personalized’, dedicated care. The individual is a trusted part of their own treatment—they fully participate in the creation and implementation of their own treatment plan. In the future, they will be living recovered, healthy lives by practicing what they learned in treatment long-term.
In stark contrast, public methadone clinics focused more heavily on personalized pharmaceutical regimens rather than engaging individuals as partners in recovery. One New York City-based clinic advertised that they ‘provide individualized dosing under close medical supervision’. Every client is an individual with specialized needs, but those needs refer more to individual bodies with varying levels of substance dependence. Patients are reduced to bodies that must be ‘dosed’ with medication. Some public methadone clinics do claim to work with clients in order to develop treatment plans, but the individual is not granted the same level of biological, psychological, and emotional complexity as those in private centers. One public hospital service claims that their ‘treatment team works closely with each client to develop an individual treatment plan with obtainable goals’. These services are geared toward helping clients reduce their opioid dependency to the best of their abilities—to return them to a state of being that is functional. Their goals are ‘obtainable’, but not lofty.
Patients of public methadone clinics are neither trusted to be a part of their own treatment, nor to learn how to self-govern. They must be governed chemically, in a way that sets them up as permanently dependent on state and pharmaceutical interventions. These forms of governance render them docile bodies that do not threaten the core population with their deviance. One public hospital spoke of methadone maintenance as a way to ‘stop the patient’s physical need for opioids and allow him/her to function in their required activities’. The goal for recovery is not to provide healing for the whole person, but to medicate the body into being able to resume docility; ‘patients’ (not clients) who are successfully put on medication will be able to ‘function’ in the utilitarian sense. The lives to which they return are described as filled with ‘required activities’, which implies a mindless fulfillment of tasks without disruption, carried out by docilized addicts.
Another public program echoes this language in its claim that: ‘[d]osage is prescribed by each clinic physician based on initial evaluation and, taken daily combined with counseling, patients can engage in productive activities that ensure successful rehabilitation’. Again, patients are passively ‘prescribed’ medication by a physician that is ‘based on [an] initial evaluation’ that is one-sided. There is no collaborative building of a treatment plan. In this case, the physician knows how to evaluate and provide adequate treatment in the form of medication, which the patient must ‘take daily’ in order for the other forms of therapy provided to be effective.
Private residential facilities, on the other hand, frame treatment as providing an avenue for a return to a normal, healthy, self-regulating life. One private center claims that its style of treatment ‘engages the whole person in the recovery process and challenges the individual to have a full, positive life with […] satisfying work’. Work is not just something which one must resume in order to recover, but is part of an emotionally meaningful and ‘satisfying’ part of a ‘full, positive life’. This contrasts heavily with the public clinic’s language of a return to ‘function’, as work is more than merely functioning, but is instead a way for an individual to thrive. The work to which people who use these treatment facilities can expect to return is prestigious: ‘[Our facility] has been successfully reconstructing lives since 1973, and many of our clients have gone on to practice law, medicine, computer science and various other occupations.’ Successfully recovered clients of this facility are able to attain high status positions, such as doctors, lawyers, and computer scientists. They are not limited, as are the patients that attend methadone clinics, to a mere return to ‘necessary activities’, but are able to ‘reconstruct their life’ and set high aspirations for their careers. Work and productivity are not just tools toward gaining recovery, but are a way of life that these individuals will be able to regain. Thus, private treatment centers’ clients demonstrate that they are self-governing through engagement in careers and high-status activities. Further, involving oneself in the white-collar workforce and similar endeavors reinforces the continuity of subjects’ self-governance and self-knowledge. This starkly contrasts with the chemically enabled necessary activities in which public treatment centers’ clients are expected to manage, and reveals how addiction discourse produces discrepant social realities and means of being governed.
Docility and governmentality: Addiction treatment and social control
Neither public nor private treatment discourses claim to cure people of addictions in the way a doctor cures a patient; rather, they seek to give people ‘tools’ they can choose to use in order to maintain recovery on their own. The burden and expectation of change rests with those who are addicted. All sites focused on ‘self-help’ and ‘choice’. However, discourse presented by public methadone clinics’ websites centered on holding individuals accountable for avoiding the bad choices to which they are prone, namely taking drugs, while private rehabilitation facilities framed their clients as making good choices in all areas of life, including but not limited to avoiding drug use. Those who attend public methadone clinics are seen as irresponsible, uncontrolled bodies when not medicated: Methadone maintenance allows individuals addicted to opiates an opportunity to focus attention on pursuing positive drug-free lifestyle choices. They can be in a better position to avoid the violence and crime sometimes associated with the street culture of drug addiction.
In the context of methadone maintenance treatment, former drug users often require medication in order to be able to avoid relapse. Methadone provides an ‘opportunity’, without which individuals would not be able to ‘focus’ on drug-free living. Left to their own devices, recovering addicts would return to participating in ‘violence and crime’, which is associated with their ‘street culture’. Methadone does not only safeguard against repeat opiate use, it also acts as a preventative measure against participation in other related acts of deviance. Without this medication, former drug users’ bodies would return to non-docility, as they are unable to govern themselves without the assistance of chemical governance. According to one public clinic’s website testimonial: Methadone saved my life. When I started I didn’t believe I could stop heroin but the methadone helped me. Then I wanted to get off the methadone and I went back to heroin. I learned I need the methadone to stay off the heroin and improve my life.
She knew herself to be unable to ‘stop heroin’ on her own, but the ‘methadone helped’ her. However, she was unable to maintain sobriety without the continued use of methadone, as she ‘learned’ when she attempted to ‘get off the methadone’. She now knows that she ‘need[s] the methadone to stay off the heroin’. Her body, when she is not assisted with a drug to self-regulate, is uncontrollable. Her story acts as a warning to other potential clients of public treatment services, conveying the message that, for public addiction service users, establishing governance over oneself is not possible without chemical support. An accompanying testimonial reads, ‘I used heroin most of my adult years. Now I’m taking buprenorphine, have improved relationships with my family, and expect to continue in my recovery from drugs.’ As in the previous testimonial, this former heroin user links taking buprenorphine with ‘improved relationships with […] family’, as if the drug gave him (or considerably contributed to) the ability to rebuild meaningful social connections. Methadone and buprenorphine are seen as vital facilitators to individuals’ abilities to take on the role of responsible adult and family member—without the medication, the people in these testimonials could not be trusted to stay away from heroin. The client’s improved relationships are indirectly credited to medication, as is his sobriety, implying that without the buprenorphine, he would not only use drugs, but also fail to function as a respectable family member and individual in society.
Clients of private rehabilitation services do not need to rely on medication for the ability to make good choices. They are trusted to take the onus to transform their lives for the better: ‘[This facility] contends that people are the captains of their own destinies, and only they can do [sic], but they cannot do it alone.’ Individuals do not just have lives; they have ‘destinies’, of which they, as ‘captains’, are directly in charge. A crew of family members and treatment professionals may support them, but it is they who are steering the ship. Private treatment discourses present themselves as ‘empowering’ and geared toward helping clients make improvements to their entire selves: ‘we believe that recovery from the disease of addiction is possible through learning from our mistakes which enables us to develop spiritually, emotionally and mentally into a more responsible and mature person’. Recovery is possible through self-growth from ‘learning from our mistakes’—clients are expected to ‘develop spiritually, emotionally and mentally’ and transform themselves into ‘a more responsible and mature’ individual. They will develop into self-governing docile subjects, rather than bodies that need to be governed partially by medication. Using the inclusive language of ‘our’ and ‘us’ implies that clients are normal people; they are part of the core population that has room for mistakes, but is ultimately trusted to self-regulate.
In public clinics, methadone plays a major role as a tool of social control over bodies, but this is not the only ‘tool’ provided them. Clients are also given ‘education’ that teaches them the ‘attitudes, skills, abilities and information’ they need to avoid deviant or criminal behavior. An essential part of the information they are given places them as populations to be governed by recovery discourses for life: ‘[t]here is no quick fix; instead, there are options that can help you take control over the long-term’. Individuals are expected to self-govern, as they are encouraged to use the ‘options’ presented them to ‘take control’ over their future lives. Public clinics’ websites promise that clients will receive basic instructions on how to live: ‘[w]hen participating in our inpatient program, patients are put on a routine that includes teaching them how to experience life without drugs or alcohol’. Patients are given a ‘routine’—explicit steps to follow that teach them ‘how to experience life’ free of deviant behavior. Their daily life must be restructured so that they can learn day-to-day responsibilities—the ins and outs of functioning—without relying on mind-altering substances. Once their practices of living are re-regimented so that they better conform to social norms of productive, responsible behavior, they are held accountable for adopting these changes ‘long-term’. Thus, in addition to medications like methadone, basic routines for functioning help shape public treatment service users into docile bodies and docile individuals. Arguably, methadone and buprenorphine make these clients able to be governed, and addiction discourse precludes the possibility that such individuals can adopt strategies of self-governance without first being governed biologically.
Private rehabilitation discourses emphasize similar restructuring of behavior, with an emphasis on a reformation of the self. Clients are provided with: ‘the self awareness and perspective to recognize their self defeating patterns of behavior, the self discipline and control to correct them […] and the education and skill to join with and contribute to the greater society’. They are given more than just ‘skills’ and ‘tools’—they are given positive attributes, like ‘self awareness and perspective’ and ‘self discipline and control’. Clients are expected not only to regulate their behavior, but also to change themselves in order to ‘contribute to the greater society’. Self-governance extends beyond regulation of deviant behavior to the transformation of non-normative inner lives. Recovery is an opportunity to get clean, but more importantly, to self-reform: We offer a program designed to promote greater self-respect, self-worth, and the ability to care for oneself and enter into health [sic] relationships […] [we provide] recreation, hobby, and leisure activities designed to help improve coordination, general physical condition, learn sportsmanship, leadership, and teamwork skills.
The focus of this treatment program is centered on improving the ‘self-respect’ and ‘self-worth’ of the client, of which the client is assured they are deserving, in addition to promoting the ability to ‘care for oneself’ and building ‘healthy relationships’. More than restructuring daily activities to keep people away from drugs, treatment focuses on improving the whole person, including the improvement of the body beyond detoxifying from drugs (‘coordination, general physical condition’) and the development of increased prosocial, interpersonal skills (‘sportsmanship, leadership, and teamwork skills’). Governmentality in private facilities is all-encompassing, reaching for all areas of the complex inner lives granted to these clients, requiring self-policing not only of behavior but also of moral selfhood.
Discussion and conclusion
The dominant framework of addiction as a disease impacts how contemporary medical practices and legal discourses approach drug use. How this way of understanding addiction translates to treatment discourses is heavily dependent on class and access to services. Clients subject to public addiction treatment discourses, especially those of methadone clinics and detox centers, emphasize a very different form of addiction medicine than do discourses presented by private residential rehabilitation facilities. The websites of public treatment services frame current and potential clients as criminal bodies that are objects of medicine, while private centers’ narratives, despite still medicalizing the ‘addict’, grant clients complex selves whose minds, bodies, and spirits must be served in order to reach the radical self-transformation that leads to a lasting recovery. The neoliberal ideal of individualism permeates both public and private addiction treatment discourses, but there are clear differences in what is expected of clients during recovery. Methadone clinic users are encouraged to return to functional lives in which they can engage in menial work and avoid incarceration, which contrasts greatly with the engaged, fulfilling, and even prestigious futures imagined for clients of private rehabilitation centers. Further, both types of treatment services perpetuate the intense self-policing central to Foucault’s concept of governmentality, but public treatment clients must first be rendered docile bodies by methadone or buprenorphine before becoming docile subjects building healthy routines and interpersonal relations. Conversely, private treatment centers also help produce docile subjects, but in a way that assists and motivates clients to achieve greatness within the boundaries of ‘normalcy’ by providing tools for self-governance that boost individuals on their path to recovery.
While many studies have focused on methadone clinics and drug courts, both of which typically cater to those in specific class and race categories, few researchers have looked at how the same theoretical tools can provide insight into how power and knowledge are deployed in private, upscale treatment settings. Our findings have considerable theoretical implications insofar as they reveal how Foucault’s concepts of governmentality and docile bodies/subjects operate across and through broader, medicalized addiction discourse in markedly different ways for different groups. We argue that more empirical and theoretical work on the role of rehabilitation centers for white, middle-class individuals as institutions of social control is vital as opioid use continues to rise for this population.
Footnotes
Acknowledgements
The authors thank Robert Granfield and Jorge Arditi for their thoughtful comments. We are also grateful to the anonymous reviewers for their helpful feedback.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.