From treatment to biography

From treatment to biography. Ungrounding of medical model in “drug addiction” intervention: a research within social –health operators

Author: Leonardo Battisti, co-author: Tommaso Bertinotti
University of Padova, Italy - General Psychology Department

This paper aims to analyze the epistemological problems about the application of the medical approach in social and health interventions on the consumption of psychoactive/stupefacient illegal substances field. In particular the research discusses operational consequences of medical approach in the construction of the identity of the user of the social services. These modalities carried out by the user and the context around it (family, friends, professionals, common people), to configure it as an individual. Indeed, concepts and praxis characterizing medicine ambit (such as sign, symptom, desease, prognosis, diagnosis, treatment) are legitimazed only if they are referred to the “organism”/to the body. When the object of an intervention is not the body (for instance human behaviour), these concepts and praxes need to be adapted to the new ambit of application. The risk is to fall into methodological, therefore operative, mistakes. Indeed in “drug abuse” treatment the medicine, through the medical model, has to deal with organic facets caused by toxic substance assumption (correlated pathologies, infections, etc.). On the other hand “social sciences” as Psychology have to deal with psychological and social implications about being “drug abuser”. However, these implications belong to an epistemological level which is different from the organic one.
This work refers to a theoretical approach called dialogical model which finds its foundament into the narrative paradigm. This approach is the same discussed in the works presented in this section of the website. This theoretical-epistemological approach proposes a scientific foundation of Psychology and in general of social sciences. Through the assumption of the narrative paradigm reality is conceptualised as a discursive configuration generated and continuously redefined by discursive practises that nominee it as such (therefore such as reality). The basic theoretical assumption is that the objects of knowledge (like the behaviour, or the mind, or the identity...) are not given into an objective way (as for organìsm in medicine), but they are generated by the discoursive ways, considered such as modalities useful to generate a specific “object” or “event”. So in the social science, such as Psychology, the “behaviour” is considered as a product of the discoursive ways made by the speaker community: comprehending both the experts (such as psychologists) and the common sense (common people). The speaker community for instance configures the reality “behaviour” in different way, depending on which discursive modality is used. In any case what is it generated is what we commonly name and manage as “real”. It means that the “words” we used configure what appears as real.
The aim of the research here presented is to investigate the social-health operators adherence to the medical model about general and specific problems in drug addiction treatment.
In order to pursue this aim, some specific sub-objectìves have been made, each one has been checked through a question, using an ad hoc questionnaire including 26 closed questions and 4 open questions. These questions have been an useful instrument to investigate the transfer of the medical model’s praxis from the proper ambit to what we call “drug abuse” ambit.
The questionnaire has been administered to doctors, nurses, psychiatrists, clinical psychologists. We chose these professionals for two reasons: first, they use the medical model when they work; second, they have an institutional role to take care the users in the italian services that work on “drug abuse”.
The questionnaires compiled and examinated through a statistical analysis are in total 465: 160 doctors, 85 psychiatrists, 97 nurses and 123 psychologists.
The research used a method called MADIT, which is a specific methodology for textual anàlysis. According to the epistemological assumptions, this methoddology allows to describe processes that build reality, in particular the modalities used by operators in drug abuse intevention. Moreover with this methodology it is possibile to work on critical aspects outlined by the research..
In this case have been used two kinds of statistical instruments: through the software SPSS for closed questions, has been done frequencies calculation and Pearson’s Chi-square. The software Spad-t has been used to analyse opened questions by lexical correspondences analysis, that is a kind of factor analysis.
Talking about the research, the first item here presented is about a central aspect of medical model and in particular of the diagnostic process: sign and symptom definitions. In fact, the label “drug abuser” is assigned through individuation of “sign” and “symptom”. With this item we intend to “investigate the operators adherence to medical model about sign and symptom definitions”.

Sign definition: the "subjective" experiences that patients might report to themselves
Simptom definition: "objective" indication of some issues that are detected by a physician during a physical examination of a patient

In this item we asked the opinion about agree/disagree into sign and symptom definitions. As you can see, the definitions are reversed, therefore wrong.
As we can see into this table, doctors’ section shows medical model adherence, because in general they disagree with the definitions (that are reversed, therefore wrong). Doctors show that they can to make a right dyagnosis based on a correct recognition and use of sign and symptom.
Instead, psychiatrists, psychologists and nurses distribute their answers between agree and disagree. This result shows the presence of a confusion about the definition of the most important elements of diagnosis process. It means that this professional categories are not in the conditions to use medical model correctly, so they can't make a right diagnosis. Consequently, they won’t be in the conditions to actualize correctly all the medical model steps that follow the diagnosis ones.

The following item allows to investigate the operative practice of “drug abuse” treatment. Therefore we want to see how the operators define drug abuse, so we asked them:

The results show that “drug abuse” is not configured through an unambiguous definition; moreover the operator uses words and elements that belong to different epistemological levels. On the contrary in medicine there is an unambiguous definition and not different versions given by each operator (for instance to make a diagnosis of cancer). Through this unambiguous definition it is possible to operate with a unique operative model (the medical model). To understand the operative implications of what the item of the questionnaire investigates, we propose an example: If these not unambiguous results were referred to the medicine field and not to the “drug abuse” treatment, we could have two doctors giving two different diagnosis (for instance gastris and pneumonia) to the same patient with the same illness.

Until now we have seen how operators configure drug addiction, now we’ll see how they intervene into drug addiction treatments. We have asked to the operators which one of the medical praxes they would to apply in a “drug addiction” intervention

The results show that all medical model praxes are considered enforceable in “drug addiction” treatment; except the prognosis. The responses are equally distributed between all kinds of response-choices, therefore without concordance among the interviewed. These responses show a strong uncertainty by operators about application of prognosis in “drug addiction” treatment.
The higher agree responses configure drug addiction as a medical disease, therefore an object of the medical model. On the contrary the uncertainty of the prognosis application shows inconsistency of the drug abuse configuration as a medical disease. In medicine therefore, carrying on diagnosis, therapy, evaluation and prevention necessarly implies the knowledge of the prognosis. In drug abuse treatment field, on the other side, experts say that they apply all the praxes of medical model, but by this results emerge they are strongly uncertain about the disease course. Therefore, the methodologically and operative wrongness that interviewed experts show in “drug abuse” treatment, is evident.
So it is only by virtue of experience (and not of theoretic and methodological competence) that it’s impossibile to say something clear about prognosis: the epidemiological data show “empirically” that it is not possible to make a prognosis, therefore we can say anything about “drug abuse” corse.

Considering these results, now we want to show the research conclusions.
In the ambit of intervention on illegal substances users, the medical model is unproperly used for two reasons: it is applied on an object which is different from the organic one (without necessary adjustments); moreover, the drug abuse diagnosis is based on uncorrect methodologically steps, therefore the nosographic category “drug addiction” is uncorrect.
The drug abuse definition given by respondents is not unambiguous, therefore it doesn’t provide knowledge elements about drug abuse: moreover, respondents don’t choose unambiguous criteria to define the assumed “disease”
Therefore, treatment objectives are not univocally defined and followed throgh a common methodology.
Not univocal objectives definition by the operators makes treatment not efficacious; in fact, there aren’t the conditions to say univocally that a prognosis is possible.
Using medical model in drug abuse field is a transposition of the medical rhetorical praxes, but not of the theoretical-methodological roles of medical model.
Therefore, making “drug addiction” diagnosis is like ascribing a linguistic label and not a clinical case explanation through signs and symptoms.
Considering the critical aspects outlined by this research, it is necessary to assume another knowledge option. This new “scientific point of view” is possible through a paradigmatic shift, to put the intervention on substances’ consumption into a right epistemological level. The proposal that we would like to present moves from a new definition of the label commonly used (“drug abuse”) which ratifies a fact; in favour of this definition “consumption of substance considered illegal”. This definition allows to accomplish two criteria: first, we can describe the process which generates the consumption as a reality, without connoting it with moral or normative assumptions. Second, it is effectively useful, because it makes possible for the “scientific community” to operate generating new realities. In fact, since we know how to “build” reality, we can also change it. Through this definition we can generate a different identity than the “drug addicted” ones.
In this way, the consumer is not considered as a sick person. This point of view is critic because it doesn’t allow us to aim reachable objectives. The consumer, or its identity, is considered as a biography that also includes the consumption of substances considered illegal. The treatment has not to go into a recover direction because it’s not methodologically correct and attainable..“Drug addiction” is not a pathology to cure (interviewed operators confirm it in the second item)
The interventions we propose, through M.A.D.I.T., aims to give occasions for reconfiguring consumer’s identity. Effectively it means that the aim is breaking processes that preserve drug addicted’s identity (seen not as a person but as a discourse), building an identity based on different discursive elements.
Moving from the discoursive way as assumption of the paradigmatic shift, the interventions will be also addressed to services network. Intervening also on “drug addiction services” means operating on all the discoursive ways that generate “drug addiction reality” from an institutional point of view. This intervention will be addressed either to the consumer or to operators. Moreover the operator has to work not only in the institutional structures, but also wherever discursive practices about this reality are generated. Therefore the competences required to the operator are knowing discursive practices used by the whole community, practices that are based on common sense: the operator’s task, so is becoming a common sense-expert to enter into these discoursive ways and to create change occasions.

CONNECTED TO THIS PAPER YOU CAN FIND:

in the section “HEALTH PSYCHOLOGY”
- Health in the territory as shared responsibility, paper and slides files

in the section “DIALOGICAL MODEL”
- Epistemological foundation and methodological exactness regarding research in the
discursive science, symposium and slides files

in the section “PSYCHOLOGY OF ORGANIZATIONS”
- The architecture of services as a tool for the health promotion within the territory, paper
and slides files

In the section “PSYCHOLOGY OF DRUG ADDICTION”
- The association “I Ragazzi della Panchina”: the construction of the discursive configuration of “drug addict” and the relation with the territory, poster file
- The generation and maintenance of stereotype of the consumer of illegal substances: an exemplification through a comparative analysis of discursive practices that characterize the Italian and the Dutch text of the law, poster file

CONTACTS
labsalute.psicologia@unipd.it