From D.A.R.E. To The Diseases of Despair

I started my doc program because I was working as a therapist in a community that was especially hard hit with the opioid epidemic. My own attitudes and beliefs about drug use and addiction have been challenged in multiple ways throughout my lifetime and nothing challenged them more than seeing the faces and hearing the stories from hundreds of people who had first-hand experience.  It is a privilege to have one’s beliefs challenged when they are fundamentally wrong or limited and there can be a lot of value and learning if we share this process. Here are some of my reflections.

Learning and Unlearning

 In the fifth grade, I changed schools twice which meant I graduated from the D.A.R.E. program twice. If you aren’t familiar, the D.A.R.E. program is a national level program intended to reduce drug use by warning school age children about the dangers. It was the first year the program had been offered in my county. Through middle school and high school my friends and I became aware of all the things we were taught that were straight up bullshit. I was offered drugs and alcohol, but I never had anyone shame me for saying no. We laughed at the ridiculous memories of cops pretending chalkboard erasers were cans of beer and the idea that government officials thought kids smoked because of a cartoon camel. As more and more peers experimented with more and more things, we also realized that you could indeed try something and not become instantly insane or addicted for life. The weapons we were given to fight the war against drugs proved to be rather useless.

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I’d argue that the D.A.R.E.  program and Just Say No! campaigns were successful if their goal was to create deeply rooted shame about drug and alcohol use. After all, if all you had to do was just say no, then drugs and alcohol must be things you CHOOSE to do, even if they are hurting you. You made a bad choice. You make continual and repeated bad choices. Shame on you. Just Say No easily becomes Just Stop which then gives way to if you choose not to stop, you should go to jail. Even though I consciously recognized the flaws in the drug and alcohol education I received, the morals remained.

I was in my late twenties before I went to college. When I first started studying psychology and learning about personal bias, I was confident that I should never be a drug and alcohol counselor. I didn’t know how I could help people that I didn’t understand. Why didn’t they just stop? If their drug or alcohol use was causing so much stress to their families, why did they continue to do that? Didn’t they love them? Didn’t they have self-respect? Why couldn’t they accept the love and help their friends and families so desperately wanted to give them? I kept that general belief system until I took addiction counseling in graduate school.

I went into that class with a bit of a chip on my shoulder. I was taking the class because it was required, not because I thought I’d ever use it. A few of my classmates worked in addiction treatment already. In world of professional counseling, you generally need a master’s degree to work directly in mental health, but you can work in addictions treatment with less education, and it can be a way that many aspiring mental health professionals gain experience. They had more to say than I did, and I didn’t want to work in addictions, so I was quieter in that class than usual. One fateful day, we watched a video that explained we don’t actually know why one person can do cocaine and remain perfectly healthy but the person next to them can drink a beer and unknowingly set off the chain reaction that ruins their life. A major reason why this is hard to pinpoint is that it is hard to ethically study. We can’t exactly shoot people up with substances and see who gets addicted and who doesn’t. This made sense in all the ways D.A.R.E. never did. Addiction suddenly had my attention. Addiction wasn’t a moral failing after all. It went beyond individual control. Who knew?

While I was more open minded and empathetic to those struggling with addiction, I still didn’t plan to work in the addiction field. I wanted to help people struggling with depression and anxiety or trauma, not drug and alcohol use. Fate intervened once more and when I had a hard time finding an internship site, I got my first full time counseling job at an inpatient drug and alcohol rehabilitation center. It proved to be both incredibility stressful and rewarding. The rewarding part came from my work with  clients and witnessing the power of empathy and human connection. The stress came from the systemic inequities that created an understaffed, overburdened work environment. After 6 months, I completed my internship, graduated and jumped ship. I didn’t have the qualifications to work as a therapist yet, but I had to GO. This led me to the world of medicated assisted treatment, or “meth clinic”. The clinic offered counseling and medications that treated opioid addiction and withdrawal symptoms.

I was drawn to the job at the clinic because it was still counseling, but it wasn’t the same demanding work environment as my internship. Working the 4pm- 12:30 am shift plus overtime at the rehab proved to be more difficult on my family than I anticipated, and the clinic hours were 5:30 am- 2pm with weekends and holidays off plus it paid more. Other than that, the only thing I knew about the clinic came from public commentary. People were usually angry about it saying it just replaced one drug with another and you could “see the junkies lining up for their fix at 5 am”.

In reality, the people who were there the earliest were there to get their medication before work. The regulations pertaining to these medications made it difficult for people to get their medicine in a private doctor’s office or pharmacy. If you were a patient at this clinic, people knew why. Were there patients who took advantage somehow, maybe they utilized the clinic option in case they couldn’t find their preferred drug that day? Maybe they cheated on their drug tests? Sure. That’s not limited to people struggling with addiction. Welcome to humanity. It seems that negative news that reinforces our core beliefs tends to travel fast and has a way of becoming “fact”, yet it’s only part of any story.

Plenty of people were there to get their medication to not experience severe withdrawal symptoms that would make it difficult to go to work or care for their children. The shame campaigns would have us believe that people struggling with addiction are bad people who make bad or stupid decisions. I never met one person who just woke up one day and started shooting heroin. Most started out using prescribed pain medications that became unavailable or unaffordable. Others used drugs or alcohol socially and things took a turn. Some were raised in an environment where drugs and alcohol were the norm. I had wanted to help people with depression, anxiety, and trauma, not addiction. I didn’t know addiction counseling also meant mental health counseling. Mostly, I was never taught that there was no addiction without pain.

It is human nature to seek relief from pain, both physical and emotional.  It is something we all have in common, yet we are taught to judge others based on how they find their relief.

We are taught how to judge based on what is shamed. Our cultural norm is to shame addiction and poverty as being the result of bad choices, yet this ignores the systemic factors that contribute to them both. This collective shaming breeds individual silence and community division. To me, this has never been brought more sharply into focus then when I went back to school for my PhD. What began as researching the opioid epidemic in Appalachia revealed patterns related to the diseases of despair and collective trauma.

The diseases of despair are suicide, substance use and alcohol induced fatty liver disease and they are associated with feelings of hopelessness and economic decline. The rates are increasing throughout the U.S. but they are especially prevalent and fatal in the Appalachian region. I find it interesting that suicide and substance use are both ways that people might self-medicate their pain. People might be more inclined to self-medicate when their pain has been publicly shamed and moralized as something they deserve. If there is more self-medicating in Appalachia, what pain is more acute here?  What makes a slow death through self-medicating preferable to seeking help? It might be the deep shame of needing help at all. It might be the shame of struggling with poverty despite a lifetime of hard work and following all the rules. It might be the shame of struggling with addiction against a system that traumatizes and shames rather than cares and treats. It might be the feeling that no real help exists.

For those of us not struggling, what do we do? Too often, we do what we’ve been taught. We judge. We tell people struggling to be tough and to pull themselves up by their bootstraps while ignoring the fact they need a pair of boots. We take comfort and pride in the good choices we have made while ignoring anything that might be sheer dumb luck or unearned advantages. If we managed to just say no to frivolous spending or the need for prescription pain relief, why couldn’t they? If they need help, why do our tax dollars need to pay for it?

We don’t all have the reason or ability to unlearn what we were taught in childhood, but it does not take a graduate degree to begin making small changes. Judgement brings a fleeting sense of power but causes us to give up the actual power that comes from our ability to show empathy and kindness. We all have more in common than we realize, but we aren’t taught to look for it. Someone profits from us internalizing shame and spewing judgment, and it’s not us. It might be unintended consequences, but it’s almost like the moralization of drug use through shame campaigns was the point. What kind of world would we live in if the beliefs of kindness and respect were reinforced instead? Let’s find out. I dare you.

Rayelle Davis is a Nationally Board Certified Counselor licensed in Maryland and West Virginia. She is an expert content reviewer for highered.com and a faculty trainer for the American Society of Addiction Medicine. Her research on the diseases of despair and Appalachia fuels her mission to build community centered around accurate and decolonized mental health education.