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‘The opposite of addiction is not sobriety; the opposite of addiction is connection.’

-Johann Hari

If possible, please watch both videos or prioritise the first video.  

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Society has shaped a view of addiction as somewhat negative and it affects the way in which we view, communicate and treat each other. This is especially noticeable among medically trained professionals who view patients who have substance abuse disorders as negative and/or ‘morally failing’ (Johns Hopkins Bloomberg School of Public Health, 2014). Society does not know whether to regard substance abuse as a treatable or manageable medical condition similar to heart disease or as a personal failing that needs to be overcome. To put this in context, I have explained a scenario below and provided two videos on the topic.

A 28-year-old female diagnosed with Guillan Barre Syndrome (GBS) was also suffering from a substance abuse disorder of Tik (Methamphetamine) and Mandrax (Methaqualone) addiction. She has been a substance abuser since the age of 16 and subsequently dropped out of school and became involved in negatively influenced social circles. She fell pregnant at age 19 and became a single mother of a now 7-year-old boy. Continuing the vicious cycle of substance abuse, she fell pregnant again at the age of 27 and was simultaneously diagnosed with HIV/Aids. She is still a single mother; her baby is now 6 months old. In the weeks following her second birth, the patient started to feel progressively weak in the arms and legs until she was no longer able to perform any functional tasks. She was admitted to hospital and diagnosed with idiopathic GBS. This was the start of a 2-month hospital stay, majority of which was in Intensive Care Unit (ICU), and a longer recovery at a rehabilitation centre or step-down facility. The GBS became the priority and the medical focus, but the patient was also dealing with the withdrawal from her substance habits, an aspect that was less focused on. Since she became unexpectedly ill and was hospitalized, her abrupt halt in her substance abuse was not her intention and was a shock to her system- mentally, physically and emotionally. But many health professionals, including myself, failed to comprehend this. In doing so, two things occurred, the abuse of patient rights and the contribution to stigma.

The scenario and my initial perception on this made me reflect on the videos shown above and I began to ask very important questions. Why did I shame my patient who was dealing with addiction and how did this affect my management of her? I realized, after introspection and reflection, that what I know and understand about addiction is incorrect and actually offensive. I used to hold a view of addiction and people dealing with addiction as harmful and undesirable, the solution only being sobriety, a state of being sober or without the influence of substance. But I have learnt that the solution is to ‘de-shame’ and to assist in the creation of meaningful connections in society, as both Johanne and Joy speak of in their respective videos. But how this can be achieved as a physiotherapist is also of great interest to me and it involves patient rights, body language, harm-reduction strategies and policy.

To understand the importance of my role as a physiotherapist, I had a look at both patient and physiotherapist rights and professional conduct. According to the South African Society of Physiotherapy, physiotherapists should at all times act in the best interests of their patients and maintain the highest standards of personal conduct and integrity in terms of transformation of the profession and healthcare services in South Africa, by adopting a culture that eliminates discrimination in all its forms, including disability, ethnicity, race, gender, nationality, class, religion and sexual orientation (SASP, 2017). In addition, in terms of their commitment to patients’ rights, they should respect patient confidentiality, privacy, choices and dignity. With regards to physiotherapists themselves, they should ensure that they are familiar with the latest requirements set in terms of ethical behaviour by relevant professional bodies and effect changes through participatory and democratic means (SASP, 2017). These statements formed the basis of my thoughts regarding this case, I knew I had not respected my patient’s choices or dignity, and this affected my ethical behaviour.

It was during this thought process that I began to think that I was indeed facing a personal ethical dilemma. My approach to this patient was different from others. What was it about her addiction disorder that prompted this thought and behavioural pattern of mine? What in fact was addiction? It is defined as the need for and use of a habit-forming substance despite knowledge the substance is harmful. People with addiction experience tolerance (more and more of the substance is required to achieve the same effect) and in the absence of the drug, they experience withdrawal symptoms (Merriam-Webster, 2009) (Bartlett, Brown, Shattell, Wright, & Lewallen, 2013). When I first met my patient, I was struck by her circumstance and social context, but instead of empathizing, I judged her. I experienced her withdrawal in our physiotherapy sessions, I was nervous around her, anxious she was going to become aggressive with me and overwhelmed by her agitation and fixation. According to Bartlett, Brown, Shattell, Wright, & Lewallen (2013), drug addiction and specifically withdrawal, exacerbates social alienation and increases risk for violent lashing out, low self-esteem and poor coping skills. When someone takes a drug, their brain releases extreme amounts of dopamine, more than the amount that is released as a result of a natural pleasurable behaviour. The brain overreacts, reducing dopamine production in an attempt to normalize these sudden, sky-high levels the drugs have created. This is how the cycle of addiction begins, over time, drug use leads to much smaller releases of dopamine (Shatterproof, 2019). Consequently, the brain’s reward centre is less receptive to pleasure and enjoyment, both from drugs, as well as from relationships or activities that a person once enjoyed. When the drug is stopped, withdrawal can be a painful physical and emotional experience as the brain finds itself in a shortage of neurotransmitters leading to a range of observable and non-observable withdrawal symptoms as it struggles to regain balance (Shatterproof, 2019). There was reason and science behind her behaviour, but did this justify my behaviour?

If I reflect on my management with her, I realise I spoke much less during treatment sessions compared to others and my treatment time was often shorter. I was nervous of her physical behaviour and her bizarre comments. She once asked me for my hair clip to put in her mouth, so she could try and distract herself, another time she tried to explain and show me the process of taking her chosen drugs, enacting the way she inhaled and positioned herself, comments like these became the norm. I clearly remember dreading my sessions with her and would sometimes think of ways for these to be shortened. I would become elated to find she was on bedrest and not for physiotherapy. I went through a phase of judgement and fell into a trap of stigma. My reaction was to simply ignore her most of the time. I thought she was a ‘junkie,’ ‘crackhead,’ weak, irresponsible, unmotivated, moody, preoccupied, and dishonest but failed to realise that my labels were creating and perpetuating stigma and consequently affecting my management of her. Stigma is a concept that describes powerful, negative perceptions commonly associated with substance abuse and addiction. According to Villa (2019), it is defined as a set of negative beliefs that a group or society hold about a topic or group of people. What I now know is that it is rarely based on facts but rather assumptions, preconceptions and generalizations, and results in prejudice, avoidance, rejection and discrimination against people who have a socially desirable trait or engage in culturally disregarded behaviours such as substance use (Villa, 2019; Link, 2001). According to the World Health Organization (WHO), stigma is a major cause of discrimination and exclusion and it contributes to the abuse of human rights, as well as patient rights and conduct with regards to physiotherapy as defined above. When someone experiences stigma they are seen as less than or weaker because of their real or perceived health status. This made sense, my perception of my patient’s health, her hygiene, her physical status of literal skin and bone and her psychological status became a barrier for me to see clearly. She experienced stigma through my perception and by some of her interactions with other patients and nursing staff, I could not imagine how this must have felt.

Because of her agitation, she refused to allow the nursing staff to wash her and this activity became difficult. She often smelled, her skin was dry and flaky and shed on the physiotherapy plinth, and her teeth were stained and rotting from the side effects of the drugs. Reflecting on this, perhaps the nursing staff avoided washing her due to their own perceptions and unethical behaviour, whether subconscious or intentional. As part of the health-care team, nurses spend 24 hours with the patient, especially in this case as she was paralyzed by the GBS. According to Bartlett, Brown, Shattell, Wright, & Lewallen (2013), when someone with addiction is approached by nursing staff or providers of healthcare with disdain and rejection, no matter how subtly, they may reject the care offered by these providers. I witnessed the nursing staff and other allied health professionals interacting with her, their shameful looks, distant care and forced interaction made me further realise how we all were contributing to the shaming of this patient and disregarding our professional roles, duties, and most importantly, our professional conduct.

According to van Boekel, Brouwers , van Weeghel , & Garretsen (2013), health professionals generally have a negative attitude towards patient’s with substance use disorders. They perceive violence, manipulation and poor motivation as impeding factors in health delivery for substance abuse patients. Not only does it negatively impact their willingness to attend treatment and access to healthcare, but it increases the rate of self-harm and reduces the self-esteem and mental health status of an individual (Monks, Topping, & Newell, 2013). Van Boekel, Brouwers , van Weeghel , & Garretsen (2013) also says that negative attitudes of health professionals towards these patients diminishes their feelings of empowerment and subsequent treatment outcomes. Obviously, my patient did not look forward to our sessions and was unmotivated, because so was I. According to Bartlett, Brown, Shattell, Wright, & Lewallen (2013), negative behaviours such as these may result in a missed opportunity for the addicted person to learn about important treatments. Furthermore, health professionals are consequently less involved and have a more task-oriented approach in the delivery of healthcare, resulting in overall less personal engagement and diminished empathy. Much-like the vicious cycle of addiction, I was on the brutal cycle of stigma.

Due to the above, society can also expect a burden on the economy and social and medical costs. Subsequently, researchers have been suggesting a change in public policy to address these issues but according to Johns Hopkins Bloomberg School of Public Health (2014), researchers have found much higher levels of public opposition to policies that might assist addicts in their recovery. Perhaps this is because majority of drugs are illegal, especially in South Africa. According to Barry, McGinty, Pescosolido, & Goldman (2014), addiction is grouped in the subcategory of mental illness and health insurance benefits group these conditions together under the framework of behavioural medicine. But because the public have different views about drug addiction and mental illness, different approaches to the stigma reduction and public policy need to be adopted. Research findings have indicated that the negative attitudes towards people with drug addiction compared with mental illness lead to lower support for policies to improve equity in insurance coverage or government funding towards improving treatment, housing and job support (Barry, McGinty, Pescosolido, & Goldman, 2014). This further establishes the need for education surrounding addiction and a society perception change. This ideal brings me to the main theme of the second video- what society understands about addiction is incorrect. If the first step of my ethical dilemma was to become aware and educate myself, then so should it be the first step in our society. Because stigma is often without facts and rather assumptions or generalizations, it can and should be prevented and reduced through education and awareness.

In the second video Johann speaks about what really causes addiction and what approaches are actually the best way to treat it. The way he speaks of this reminds me of how we treat other patients with mental illness or even chronic health conditions such as hypertension or heart disease. According to Anton (2010), recognizing addiction as a disease much like diabetes or asthma is the only way addictions and its sequelae will be addressed adequately, with more effective treatment approaches or even cures found. Patients who default on their hypertension medication are not seen as ‘falling off the wagon,’ contradictory to someone battling with a Tik addiction failing with treatment or sobriety. Missing from these stories are actually the experiences of patients who do overcome their addiction and live a life of connection and bonding. More recently, it is socially acceptable to speak up about one’s mental struggles with a mental illness or chronic condition but the same conversation around addiction gives way to an opinion that addiction is bad and that the person is weak. Perhaps this is again strengthened by the fact that many substances are illegal (Johns Hopkins Bloomberg School of Public Health, 2014). I experienced this with my patient, I saw her as inferior to myself and held this idea of criminality and wrong doing in my head and in my body language. According to a study carried out by the University of Pennsylvania, majority of communication is transmitted non-verbally, 70% is via body language, 23% is tone of voice and inflection and 7% is spoken words (Aurora Health Care, 2008). Reading this shocked me, I knew my body language was the main component in my behaviour towards my patient and I consequently realized that body language holds a high standard in my profession, body language and physiotherapy almost go hand in hand. I was never sitting behind a desk with this patient, I was in the gym physically handling her body, especially because she was paralysed by the GBS. I was providing treatment that involved the use of my own body and the idea of body language did not cross my mind at the time, my arms were held in a stiff-like manner, I avoided touching her without gloves, washed my hands numerous times throughout our sessions, and I would keep a distance from the plinth.

Joy speaks about the difficulty of becoming sober, she says ‘When you are caught up in your disease, you can’t see nothing but your pain.’ I realized that it is one thing to attempt becoming sober at will, but another to be unexpectedly thrown into the circumstance of withdrawal. Through Joy’s story I understand what Johanne is meaning when he speaks about connection. Joy says in the beginning of the video, ‘The first time I tried heroine, not only did I like it, I loved it. It gave me a sense of peace that I didn’t have to worry about stuff anymore.’ Johanne says addiction is about not being able to bear the presence of your life. Remember, my patient was is a single mother with little social support and no schooling or employment, her substance use was her coping mechanism. It astounds me that the environment in which majority of South Africans lives doesn’t provide for opportunity of connection and is rather full of barriers and abandonment. This is where the problem lies. I picture my patient returning to the ‘Rat Cage’ of two water bottles, one with drug laced water and another with normal water. The drug laced water being encouraged by the poverty, crime, poor living conditions and lack of social construct and the normal water being driven by the minority that are invested in society and their lives. Instead of a lush ‘Rat Park’ where there is choice, support, connection, opportunity and stable relationships, she returns to a circle of unemployment, poverty and ill-health. Now, I completely agree that addiction is a problem of bonding, her connection or involvement in society is constantly being threatened. Knowing this, I realize that my judgement was ill placed and uneducated but mostly, lacked understanding. My attitude should be more considerate, open, and sympathetic.

Health professional’s behaviour towards substance users is not well researched, especially in terms of body language and communication. As mentioned about, I know that 70% of communication is non-verbal but how can this directly relate to physiotherapy? According to Hargreaves (1982), non-verbal behaviour forms the major part of communication; responses in interactions are based on the subconscious perception and interpretation of non-verbal messages. Perhaps my patient’s comments and her physical status and ill hygiene contributed to my subconscious perception? Hargreaves (1982) says that through intuition and experience, most physiotherapists develop the skills necessary to aid their understanding of the behaviour and responses of patients. Increased awareness of non-verbal skills and the importance of their use will enhance both the physiotherapist-patient relationship and the quality of treatment. In addition, Bartlett, Brown, Shattell, Wright, & Lewallen (2013) states that incorporating harm reduction strategies and evidence-based interventions in working with persons with addiction yields the best opportunities for helping them get the care and treatment they need. Providing basic knowledge to people with addiction could not only help with the safe use their drug of choice but could help in the development of a trusting relationship that might lead the person to seek help to overcome the addiction. Persons with addiction also need information on how to dispose of syringes and other drug administration items safely. Lack of information not only puts these individuals at risk, but also others in society (Harm Reduction Coalition, n.d.). Furthermore, replacing negative attitudes with evidence-based interventions to treat persons with addiction is key in helping them achieve the highest level of health possible. Cleary, Hunt, Malins, Matheson, and Escott (2009) found the knowledge and attitudes of caregivers and family members toward persons with substance abuse could be improved through education on substance use/abuse and strategies to support those experiencing these conditions. However, even among trained substance abuse counsellors, resistance is evident to the adoption of evidence-based practices in the treatment of persons with addiction. Thus, education of all care providers about the nature of and treatment for addiction may be needed to improve health care (Ducharme, Knudsen, Abraham, & Roman, 2010).

If one looks at the Portugal scenario, it becomes evident that the legalisation of certain drugs and the inclusion of drug addicts into employment and rehabilitation programmes provides for a 50% decreased in the overdose rates. If this were to occur in South Africa along with policy change in support for recovering addicts, I believe the rate and prevalence of addiction would decrease and simultaneously the crime and poverty would decrease. It would start to create more of a Rat Park environment and lessen the load on the healthcare systems of our country. More holistically, this would lead to a reduction in shame and consequently, reduced number of health professional ethical predicaments experienced. Subsequently, the communities will be more likely to be in a position to change attitudes and to get people the help they need. Beth McGinty, an assistant professor in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health says, ‘if you can educate the public that these are treatable conditions, we will see higher levels of support for policy changes that benefit people with mental illness and drug addiction.’

But education does not stop with people in our communities, it requires all networks and especially among health professionals who deal with these patients at their most weak and who intercept at the phase of reintegration into society. Of the two health professionals that spend the most time with hospitalized patients, physiotherapists and nurses need to be of the utmost priority. As Johann says, ‘When we shame our patients, we put barriers in place that prevent them from making connections in their lives.’ We increase the idea of patients not being able to bear the presence of their lives. A physiotherapist can provide for the opportunity of connection instead of contributing to shame, this begins with patient rights, our body language harm reduction education, and our general understanding of humanity. I wrote this piece towards the end of my block and towards the end of my time with this patient, I worked hard to change my behaviour and I noted this change when both my patient and I found it difficult to say goodbye.

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References

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Aurora Health Care. (2008). Aurora Employee Assistance Program: The Art of Communication.

Barry, C. L., McGinty, E. E., Pescosolido, B., & Goldman, H. H. (2014, October). Stigma, Discrimination, Treatment Effectiveness and Policy Support: Comparing Public Views about Drug Addiction with Mental Illness. Psychiatr Serv., 1269–1272.

Bartlett, R., Brown, L., Shattell, M., Wright, T., & Lewallen, L. (2013). Harm Reduction: Compassionate Care Of Persons with Addictions. Medsurg Nursing, 22(6), 349–358.

Cleary, M., Hunt, G., Malins, G., Matheson, S., & Escott, P. (2009). Drug and alcohol education for consumer workers and caregivers: A pilot project assessing attitudes toward persons with mental illness and problematic substance use. Archives of Psychiatric Nursing, 23(2), 104-110.

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Johns Hopkins Bloomberg School of Public Health. (2014, October 1). Study: Public Feels More Negative Toward People With Drug Addiction Than Those With Mental Illness. ScienceDaily.

Link, B., & Phelan, J. (2001). Conceptualizing stigma. . Annual review of sociology, 363-385.

Merriam-Webster. (2009). Addiction. Retrieved from Merriam-Webster ‘s Online Dictionary: http://www.merriamwebster.com/dictionary/addiction

Monks, R., Topping, A., & Newell, R. (2013). The dissonant care management of illicit drug users in medical wards, the views of nurses and patients: A grounded theory study. Journal of advanced nursing, 69(4), 935-946.

SASP. (2017). South African Society of Physiotherapy: Code of Conduct.

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van Boekel, L., Brouwers , E., van Weeghel , J., & Garretsen, H. (2013). Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: Systematic review. Drug and Alcohol Dependence, 23-35.

Villa, L. (2019, February 20). Shaming the Sick: Addiction and Stigma. Retrieved from DRUGABUSE.COM: https://drugabuse.com/addiction/stigma/

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