Addiction and Recovery in Dutch Governmental and Practice-Level Drug Policy: What’s the Problem Represented to be?

Abstract

Around 2009, ‘recovery’ was introduced in the Netherlands as a new approach to drug addiction and addiction services. Recovery is now featured in practice-level policy but is absent in governmental drug policy. To investigate whether the Dutch recovery vision is coherent with governmental drug policy, we apply Bacchi’s What’s the problem represented to be? approach to analyse problematizations of ‘drug addiction’. We analysed two influential practice-level policy documents and one governmental drug policy document. We found that governmental policy addresses the harms and public nuisance of drug addiction, whilst practice-level policy addresses the wellbeing of persons with addiction. Despite these different starting points, the Dutch recovery vision seems coherent with both problematizations. Its adoption in the Netherlands was less subject to political debate compared to other countries. This may be a result of recovery being driven by bottom-up efforts without government intervention, leading to constructive ambiguity between government- and practice-level policies.

Keywords

addiction recovery drug policy practice-level policy problematization bacchi Netherlands

Introduction

Drug policy in the Netherlands is historically controversial. The essence of this reputation can be traced back to the late 1960s, when Dutch drug policy deviated from international standards and framed drugs more as a public health and social issue, instead of a criminal (justice) issue (Grund & Breeksema, 2018). Consequently, most of Dutch drug policy became the responsibility of the Ministry of Health. Dutch strategies for addiction services, harm reduction and prevention of marginalization and stigmatization of drug users reflect this health focus. In the late 1970s and early 80s, for example, a shift in the Netherlands occurred, when traditional drug treatment services were criticized by user organizations, left-wing political parties and progressive treatment professionals for their abstinence-only focus and poor results (Tops, 2006). The Netherlands became the first place in the world to have government-approved needle exchange and supervised injecting facilities and has had drug-testing available as early as 1992, as part of an early warning program combining surveillance and harm reduction (Ritter & Cameron, 2005; Spruit, 2001; Tops, 2006). Another famous example is the so-called tolerance policy (‘gedoogbeleid’ in Dutch) allowing the possession and sale of a limited amount of cannabis products in ‘coffee shops’, which was initiated to protect cannabis users from engaging with more harmful substances, by separating the cannabis (soft drug) market from the hard drug market (Blok, 2011; van Laar & van Ooyen-Houben, 2009).¹ In the late 80s, however, Dutch drug policy changed direction and got increasingly repressive, as law enforcement programs were initiated to reduce drug-related public nuisance, aimed at people who use drugs (Mol & Trautmann, 1991).²

The current Dutch drug policy is primarily based on a white paper from 1995 (Nota ‘Het Nederlandse drugbeleid: continuïteit en verandering’ – Drugbeleid, 1995) and has since only been complemented with specific subjects, mostly around law enforcement (van Laar & van Ooyen-Houben, 2009). In the following years, much of the (mental) health sector was privatized (Zorgverzekeringswet, 2006) and Dutch drug addiction services could evolve almost independently from governmental drug policy. As such, they are now independent organizations that are financed through health insurance.³ The 15 largest addiction service providers are affiliated with the branch organization ‘The Dutch Mental Health Sector’ (‘De Nederlandse GGZ’). Consequently, we can distinguish two types of policy that address drug addiction in the Netherlands: one drafted by the Dutch national government, in the form of drug policy (including both public health and law enforcement perspectives), and the other drafted by the Dutch mental health and specialised addiction sector, representing the practice-level policy of addiction services (see Figure 1). Dutch governmental drug policy consists of a whitepaper and a myriad of ‘letters to parliament’, whilst practice-level addiction policy consists of a few key vision and mission documents and guidelines from the national branch organization. Although both types of policies address drug addiction, they start from fundamentally different premises about the problem of drug addiction. So far, no studies have compared these two types of policies.

Around 2009, the concept of recovery was introduced in the Netherlands as a new approach to deal with addiction. This new concept, which originated in the United States (US) is also gaining interest in other parts of the world, challenges existing addiction service approaches, and is often described as a paradigm shift (Davidson & White, 2007). Briefly, it is described as a shift from a clinical disorder-oriented approach, characterized by a focus on symptoms of addiction (and symptom reduction), towards a person-centred and broader wellbeing-oriented approach, through learning from lived experience (White, 2007). Typically, a clinician is more concerned with remission of symptoms and outcomes of addiction treatment, whilst a person who experiences addiction may be more concerned with things as loneliness, stigma or identity, and the process of getting better (Davidson & Roe, 2007). Whilst a definition of recovery is still debated, it is increasingly agreed upon that recovery is a process that can take place in various ways, depending on circumstances, and may include improvements in multiple life domains, such as housing, relationships, employment and wellbeing (Kaskutas et al., 2014; Neale et al., 2014). In the Netherlands, most addiction services have embraced recovery as a concept to approach addiction. Directors of the largest treatment providers agreed to endorse recovery through the Charter of Maastricht, initiated by a service user advocacy organization who emphasized the need for a broader focus of recovery in addiction services at that time (Charter of Maastricht, 2010). Recovery is now featured in three practice-level policy documents (Expertise Center Forensic Psychiatry, 2020; GGZ Nederland, 2009, 2013) and in the recently developed national Standards of Care (2017–2020).⁴ The Dutch governmental drug policy (Nota ‘Het Nederlandse drugbeleid: continuïteit en verandering’ – Drugbeleid, 1995) uses the term recovery in relation to addiction but here it refers to merely becoming abstinent which is not the same concept of recovery as described above. No Dutch governmental drug recovery policy currently exists.

The historical reputation of the Netherlands has often made the country subject of international debate on drug policy. However, with the legalisation of cannabis in countries such as Canada, Uruguay and the US, the Netherlands no longer deviates as much internationally with its tolerance policy or other public health focused drug approaches, including harm reduction strategies. However, Dutch addiction services have adopted a seemingly new approach to drug addiction which merits attention, particularly because of the way they have adopted it. It appears that, opposed to other countries which have endorsed the addiction recovery concept in governmental drug policy, recovery is adopted bottom-up in the Netherlands without involvement of the government (Bellaert et al., 2021). Furthermore, whilst different international studies have described problematizations of drug policy and translations of recovery movements into drug policy ideas (Fomiatti, 2017; Gilman, 2011; Humphreys & Lembke, 2014; Lancaster, Duke, & Ritter, 2015; Thomas, Bull, Dioso-Villa, & Smith, 2019), we are not aware of any studies that look at practice-level policies in relation to governmental-level drug policies. Given that the recovery movement is gaining interest in other European countries as well (Bellaert et al., 2021), the Dutch case can be particularly relevant for an international audience.

To understand to what extent recent developments in the Netherlands in the practice of drug addiction services are coherent with the unchanged and older Dutch governmental drug policy, this paper aims to reveal and compare the rationale through which two types of policy address the problem of drug addiction: government-level drug policy and practice-level addiction policy. To do so, we analysed the problematization of drug addiction by applying the ‘What’s the Problem Represented to be?’ (WPR) approach (Bacchi, 2009; Bacchi & Goodwin, 2016) to analyse both policies.

Literature

From a theoretical perspective, scientists debated the concept of drug addiction. Historically, addiction has been framed as ‘moral failure’ (Siegler & Osmond, 1968), a disease (Jellinek, 1960) and a biopsychosocial phenomenon (Engel, 1977), for example. More recently, influential institutes, such as the US National Institute on Drug Abuse, consider drug addiction to be a chronic and relapsing brain disorder (National Institute on Drug Abuse, 2021). At the same time, other researchers refute the idea that drug addiction is a brain disorder by emphasizing the psychological and social aspects of addiction (Heather et al., 2018). As such, different definitions of drug addiction and assumptions of the underlying mechanisms of drug addiction currently co-exist in the academic world. Furthermore, some argue that because of these variations over time and contexts, addiction should not be seen as an actual existing condition, but rather as a social construct that is subject to power struggles, cultural and political developments and events (Levine, 1978; O’Mahony, 2019; Seddon, 2009). More widely accepted is the notion that drug addiction has a major impact on health and consequently on the ability to live a fulfilling and productive life. From a policy perspective, this impact of drug addiction on health is an important driver for policy development.

In the last two decades, several shifts towards addiction recovery-oriented governmental drug policies have taken place, particularly in the US, the United Kingdom (UK) and Australia. Scholarly work critically examined these recovery movements (D. Best et al., 2010; Braslow, 2013; Duke, 2013; Fomiatti, 2020; Fomiatti, Moore, & Fraser, 2017; Lancaster et al., 2015; Neale et al., 2014; Seear & Fraser, 2014; Thomas et al., 2019). Whilst the term ‘recovery’ is strongly linked to the abstinence-based Alcoholics Anonymous and other 12 step fellowships, addiction recovery as used in this paper is mainly influenced by the parallel mental health recovery movement (Davidson & White, 2007; White, 1998). Discussing this parallel mental health recovery movement in the US, Braslow (2013) argues that although recovery is framed as a revolutionary answer to the deinstitutionalization and the psychopharmaceutical revolution in mental health, many recovery ideas were already broadly supported by the medical and mental health sector. Additionally, Braslow (2013) describes recovery in the US as deeply embedded within sociocultural values of neoliberalism, because of the focus on the individual and his or her own responsibility. In the UK, studies also linked the reframing of drug policy towards recovery to parallel developments within wider political, economic and social contexts. Duke (2013) argues, for example that the strategies behind the Big Society agenda (Cameron, 2010), with underlying emphases on neoliberal values (e.g. empowerment, freedom, citizenship and responsibility), ‘fit easily within the recovery agenda, which places emphasis on the role of individuals, families, communities, and volunteers in supporting the recovery process’ (Duke, 2013, p. 48). A comparative study of UK and Australian drug policy documents that feature recovery underlined this observation (Lancaster et al., 2015). In both countries, drug policy frames all drug use and dependency as a problem of the individual needing ‘curative attention’, ignoring alternative experiences of drug use and health paradigms (Lancaster et al., 2015).

Besides revealing how recovery is framed, policy analyses in the US, UK and Australia also describe the translation of recovery movements into policy ideas. Humphreys and Lembke (2014) describe how both in the US and in the UK dissatisfaction with the addiction service system combined with the prominent role of (academic) recovery advocates was key in the development of recovery policies. In the US, government funded programs, such as the Recovering Community Services Program, and the Substance Abuse and Mental Health Services Administration (SAMHSA) allowed addiction services to organize themselves, paving the way for a shared advocacy agenda and the adaptation of recovery as a cornerstone of federal drug policy (Humphreys & Lembke, 2014; Humphreys & McLellan, 2010). These US recovery advocates also increasingly inspired actors in the UK and offered new ideas on how to organize addiction services (Best et al., 2010; Gilman, 2011). By 2008, recovery was featured prominently in UK governmental drug policy (UK Drug Policy Commission, 2008). In Australia, new recovery policy ideas were in turn influenced by UK advocates in a similar fashion (Fomiatti, 2017; Thomas et al., 2019).

In sum, these international recovery movements shared dissatisfaction with systems of addiction services and saw a prominent role for academic advocates of new recovery policy ideas. Furthermore, researchers have criticized the adoption of recovery in several national drug policies for imposing certain political values and citizenship goals upon drug users. So far, emerging recovery movements in continental Europe, including in the Netherlands, have received limited scholarly attention, and there are no studies yet examining its influence on drug or addiction policies (Vanderplasschen & Vander Laenen, 2017).

Approach

Inspired by Foucault’s (1988) work on ‘problematization’ and ‘thinking problematically’, the study of problematizations in drug policy has seen a recent uptake, particularly in the US and Australia. In a recent special issue in the International Journal of Drug Policy (Houborg et al., 2020), drug scholars applied Bacchi’s (2009; Bacchi & Goodwin, 2016) post-structural analytic strategy 'Whats (WPR approach) to study problematizations in drug policy. In short, Bacchi (2009) argues that instead of policy simply addressing problems as they emerge, problems are constructed in a certain way by integrating particular facts, values, theories and interests. In other words, a problem is produced as a particular type of problem that needs regulation or intervention in a particular way. Studying such problematizations gives insights into underlying assumptions of policy and can also reveal ‘silenced’ assumptions that are often not made explicit. Using this method, Lancaster et al. (2015: p.617) argued, for example that key reports on the place of recovery in Australian and UK drug policy framed people who use drugs ‘as worthy of citizenship in the context of treatment and recovery’. However, this also implicated a silenced assumption, namely that those who continue to use drugs are unworthy of such rights. We are not aware of studies applying Bacchi’s (2009) WPR approach to recovery in continental Europe. In the Netherlands, despite its historically controversial drug policy, a strong tradition of monitoring and evaluation of drug policy (van Laar & van Ooyen-Houben, 2009), and the introduction of addiction recovery in practice-level policy documents since 2013, no policy studies around addiction recovery have yet been performed.

As a tool, the WPR approach formulates six methodological questions, which we outlined in Table 1. The application of this approach to drug policy and related subjects has led to a diversity of analyses highlighting different ways of thinking about governmentality and laying bare potential stigmatizing or marginalizing effects of said policies (Houborg et al., 2020; Seear & Fraser, 2014).

Table 1.

Questions from the WPR approach.

What’s the Problem Represented to Be? (WPR Approach)
1. What is the problem represented to be?
2. What presuppositions or assumptions underlie the representation of this problem?
3. How has this representation of the problem come about?
4. What is left unproblematic in the problem representation? Where are the silences? Can the problem be conceptualised differently?
5. What effects (discursive, subjective, lived) are produced by this representation of the problem?
6. How/where has this representation of the ‘problem’ been produced, disseminated, and defended? How could it be questioned, disrupted and replaced?
Source: Paraphrased from Bacchi and Goodwin (2016, p. 20)

Method

We collected the data in this paper as part of a larger European study (REC-PATH) in the Netherlands, Belgium and the UK that focuses on examining personal and structural factors that influence drug addiction recovery pathways (Best et al., 2018). Fundamentally, studying recovery pathways of individuals (see for examples: Best et al., 2021; Martinelli, Nagelhout, et al., 2020a; Martinelli, van de Mheen, et al., 2020), requires studying the policy context in which addiction and recovery occur and evolve (Bellaert et al., 2021). For REC-PATH, the authors have extensively engaged with and published international recovery literature before writing this paper. Each national research team in the project was tasked with studying the recovery policy in their respective country, without specific requirements of that investigation. This WPR-study was approached as a distinct project and the findings are not particularly linked to results of the larger project.

We analysed two practice-level addiction policy documents and one government-level drug policy document (Table 2). The practice-level policy document by ‘The Dutch Mental Health Care Sector’ (GGZ Nederland, 2013) represents the most influential document as it covers the largest addiction service providers in the Netherlands. The other practice-level document by the Expertise Centre Forensic Psychiatry represents a more specialised document that covers drug addiction treatment in forensic settings. We selected these documents because they are the most recent comprehensive and influential policy documents available that address drug addiction in the Netherlands. The documents were all published in Dutch and analysed by the first author whose native language is Dutch.

Table 2.

Documents used for analysis.

Policy Documents	Published by	Year
Dutch drug policy: Continuity and change	Ministry of health	1995
A vision on addiction and addiction services	The Dutch mental health care sector	2013
National care program for forensic addiction services	Expertise centre forensic psychiatry	2014–2020^*

^*First published in 2014 and updated several times with minor changes, last update in 2020.

The WPR approach (Bacchi, 2009; Bacchi & Goodwin, 2016) was used for analyses of the policy documents. Guided by the questions outlined in Table 1, the first author investigated how addiction is problematized in Dutch drug policy and in practice-level policy. After examining assumptions and issues that are framed as ‘problems’, we reflected on what was framed as a solution to the problem of addiction. In each step of the analysis, the first author discussed results via online video calls with the second and last author, who are both senior drug scholars with ample expertise in policy research internationally and in the Netherlands. We encountered no major disagreements in these discussions, however, the senior co-authors occasionally provided or asked for additional information or literature around certain topics of the investigation that helped to validate interpretation. Finally, a draft of the manuscript was presented to the third author who, without prior involvement, joined the final discussion on the interpretation of the findings. This discussion helped to resolve some unclarities in the manuscript. This expert-reflection strengthened the validity and credibility of the problem interpretation.

Firstly, we scrutinized and analysed the policy documents. The analysis focused on identifying for each type of policy: problem representations of drug addiction (Q1, Table 1); assumptions underpinning these problem representations (Q2, Table 1); what was left unproblematized in these representations (Q4, Table 1); and alternative ways of framing of representations (Q6, Table 1). Scrutinizing the documents in this way allowed us to think about the potential effects that are produced by these problem representations (Q5, Table 1) and how the concept of recovery fits in this context.

Results

Problematization of ‘Drug Addiction’ in Governmental Drug Policy

The problem of drug addiction represented in Dutch governmental drug policy, is about drug use and risks for public health. However, not all drug use is seen as an unacceptable risk to public health. This depends on ‘the circumstances under which and the extent to which drug use takes place’ (Nota ‘Het Nederlandse drugbeleid: continuïteit en verandering’ – Drugbeleid 1995: p.4). Particularly drug use that results in social and individual harms is considered problematic in the governmental drug policy. People who use drugs problematically, referred to as addicts, are individuals that cause harm to themselves or to their environment. Furthermore, drug addiction is described as a lifestyle and a form of ‘expression of social or cultural resistance for youth’, which is purposively discouraged by withholding repressive law enforcement (so there is nothing to resist against) (Nota ‘Het Nederlandse drugbeleid: continuïteit en verandering’ – Drugbeleid, 1995: p.8).

Notably, only hard drug use is problematized. The Dutch ‘Opium Act’ (Act of 23rd of June 1976, 1976) makes a distinction between drugs with acceptable risks, referred to as soft drugs (including cannabis products), and drugs with unacceptable risks named hard drugs (including heroin and cocaine for example). Cannabis use is explicitly unproblematized in Dutch drug policy: ‘the risks of cannabis use are not qualified as “unacceptable", in contrast to the risks associated with the use of hard drugs, such as heroin’ (Nota ‘Het Nederlandse drugbeleid: continuïteit en verandering’ – Drugbeleid, 1995: p.36). Thus, the problematized subjects of drug addiction in Dutch governmental drug policy are persons that use hard drugs in a way that results in harms to themselves or to others.

The distinction made here, between acceptable and unacceptable drug use, is a so-called dividing practice. According to Bacchi and Goodwin (2016), practices of differentiation and subordination are fundamental governing mechanisms. Here, based on the substance(s) they use, the Dutch drug policy produces the idea that there are different categories of people with drug addictions who require different types of governing. The underlying assumption is that the extent of individual and social harms is associated with the type of substance(s) a person uses. This distinction justifies the tolerance policy towards cannabis users and a tougher repressive approach towards hard drug users. In practice, this means that the police may, but generally will not, address someone that uses cannabis in a public place (unless this use causes obvious nuisance to others), whilst users of other illicit drugs will have an increased chance of being addressed by police. Discriminatory enforcement of drug policy may be exceptional; however, Uitermark (2004: p.518) argues that this flexible approach to drug enforcement offers more opportunities to set ‘sophisticated and sensible priorities’ compared to a fixed prohibitionist approach. It allows one to weigh the undesired effects of criminalization of users and other policy measures against one another (de Kort & Cramer, 1999).

The rationale of setting policy priorities based on harm and risk assessment of substances has also been proposed in the research of Nutt et al. (2007, 2010), King, Saulsbury, & Blakemore (2010), for example. The authors argued that the relative harms of substances correlate poorly with the UK national drug classification and that this called for a reconsideration of said policy ( Nutt et al., 2010; Tran, 2009). However, in both the Dutch drug policy and the Opium law, the criteria to establish whether a substance is harmful are only vaguely described using the terms ‘health damage’ or ‘addiction’ (only liver and kidney damage are explicitly mentioned in relation to XTC use: Nota ‘Het Nederlandse drugbeleid: continuïteit en verandering’ – Drugbeleid, 1995: p.17). More prominently, the number of people that use a certain drug and the number of people that are addicted to it, are considered an indicator of the harmfulness of that drug by Dutch drug policy. These numbers are also considered an indicator of drug policy success (or failure):

“However different views on drug policies may be, there is broad consensus on the ultimate criterion by which to assess the effectiveness of any national drug policy. This is of course the magnitude of and changes in the number of hard drug addicts and in particular the number of hard drug users under the age of 21.” (Nota “Het Nederlandse drugbeleid: continuïteit en verandering” - Drugbeleid, 1995: p.7)

Whilst the number of ‘hard drug addicts’ was considered relatively low in 1995, as stated in the document, it was considered a ‘major societal and administrative problem’ bothering communities (Nota ‘Het Nederlandse drugbeleid: continuïteit en verandering’ – Drugbeleid, 1995: p.9). This nuisance is caused by ‘large numbers of property crimes to acquire money for the purchase of drugs’ and ‘an extremely maladaptive lifestyle of which stray behaviour, (poly) drug use and crime are mutually reinforcing elements’ (Nota ‘Het Nederlandse drugbeleid: continuïteit en verandering Drugbeleid’ 1995: p.9). However, the document also explains that nuisance is often incorrectly attributed to persons with drug addiction and that nuisance is actually part of a wider problem of social marginalization. Here, one could even say that the Dutch drug policy performs an analysis of the problematization of drug addiction herself. The document argues that the proposed underlying assumption of this problem, namely nuisance by persons with drug addiction, is incorrect. Regardless, ‘nuisance from hard drug users’ is still presented as part of the problem of drug addiction. The accommodation of both pointing out and recognizing social marginalization as an underlying assumption for nuisance and at the same time ascribing blame to ‘drug addicts’ in this policy may be the result of the typical Dutch polder model. This political mechanism, is described as a pragmatic recognition of pluriformity (Kuipers, 2015) and refers to a broader practice of cautious governance where different stakeholders try to reach outcomes that are acceptable for all. It can be seen as an alternative to authoritarian governance and emphasizes the role of the government as primus inter pares – important, but not imposing (Delsen, 2000; Uitermark, 2004).

Proposed solution to the problem of addiction

In response to the nuisance problem, Dutch drug policy aims to ‘condition the behaviour’ of persons with drug addiction by ‘sanctioning deviant behaviour’ and ‘rewarding correct behaviour’, although without explicitly stating how this will be achieved (Nota ‘Het Nederlandse drugbeleid: continuïteit en verandering Drugbeleid’, 1995: p53). This approach implies an interpretation of drug addiction as rational choice behaviour, whereby the problem subject is in control of and responsible for his or her behaviour, which is assumed conditionable. This interpretation is underlined in the policy document when two ‘key concepts’ for drug treatment are discussed, namely (1) responsibility and (2) reciprocity:

“Addicts need to accept responsibility for their own behaviour. Being addicted is no excuse for causing nuisance to others. The second concept, reciprocity, means it is expected that in return for the help provided, the addict at least adheres to what was agreed upon with support services.” (Nota “Het Nederlandse drugbeleid: continuïteit en verandering Drugbeleid”, 1995: p.26)

The policy document simultaneously calls for the need to offer ‘opportunities to also address aspects such as social disadvantage, housing and social skills’, in the context of demand-oriented addiction treatment (Nota ‘Het Nederlandse drugbeleid: continuïteit en verandering Drugbeleid’, 1995: p.26). This latter statement proposes that the problem of addiction is about more than hard drug use and rational choice behaviour, and that structural inequalities and social disadvantages are also underlying to the problem of drug addiction. Here again, multiple problem representations on the same subject are proposed. This may be the result of more poldering, as opposing views on how much responsibility can be attributed to behaviour of individuals can differ across political spectrums (Brewer & Stonecash, 2015). In the Netherlands, with a multi-party government and house of representatives, such opposing viewpoints on individual responsibility also exist between parties (Berg, Harting, & Stronks, 2021). Generally speaking, right-wing parties attribute more responsibility to individual behaviour compared to left-wing parties. We shall discuss some of the implications of the described problematization of drug addiction in the concluding thoughts, after addressing the problematization of addiction in practice-level policy.

Problematization of ‘Addiction’ in Practice-level Policy

As stated in the introduction, Dutch practice-level addiction policy developed without much interference from the governmental Drug policy. Whilst both policies address the problem of drug addiction, they do so from different starting point and within different contexts (see Figure 1).

Problematization of drug addiction by the addiction services

The problem represented in Dutch practice-level policy is that drug addiction constitutes a broad range of health, social, societal and personal harms to individuals. Moreover, this problematization is not limited to illicit drugs, but also addresses problematic use of legal substances, such as alcohol, and behavioural addictions. No specific substances are problematized more than others or are left unproblematized. Thus, unlike in the Dutch drug policy, cannabis use is considered equally problematic as other substances in the practice-level policy documents. Problematized subjects are those who have gotten into ‘serious problems’ because of their addiction or who cause harm to their environment. Furthermore, a future focus on the following ‘vulnerable groups’ is stated: ‘young people, people with mild mental disabilities, the elderly and people with comorbid problems’ (GGZ Nederland, 2013, p. 29).

The practice-level policy also performs divisive practices by making a distinction between substance addiction and abuse, similar to how substance ‘use, misuse and dependence’ are distinguished in Australia’s National Drug Strategy (Fomiatti, 2020, p. 4). In the Dutch practice-level policy, abuse is described as continued heavy use of substances that causes problems and is considered to be a pre-stage of addiction and easier resolvable compared to addiction. This justifies the need for different levels of treatment intensity and duration.

Furthermore, the document criticizes a societal trend and government policy for being ‘permissive’ towards substance use:

“The addiction services sector wants to increasingly counter the permissive attitude that has been outlined over the past decades – also by the Dutch government.” (GGZ Nederland, 2013, p. 11, p. 11)

By criticizing a ‘permissive attitude’ towards substance use, this statement implies that the document has different notions as to what harms or risks are acceptable compared to Dutch society and government. It suggests that a stricter or intolerant (opposed to ‘permissive’) attitude towards substance use is necessary. By producing the public’s and government’s attitude as a problem, the statement proposes that a certain public attitude can influence the emergence, continuation or even worsening of addiction problems. This assumption is similar to the ‘normalization thesis’ that followed after the 1980s dance/rave boom in the UK which argued that (recreational) use of some drugs (e.g. cannabis, XTC and amphetamines) had become so common for youth, that it was no longer considered deviant behaviour and was normalized. The original authors (Parker, Measham, & Aldridge 1995: p.26) went on to predict that ‘non drug-trying adolescents will be a minority group’. This theory was soon criticized for exaggerating the extent of drug use, simplifying choices young people make and ignoring the meaning that drug use had for them (Shiner & Newburn, 1997). Similarly, assuming that a permissive public attitude leads to more addiction problems may be a simplification of reality.

Another proposed problem of addiction in the practice-level policy document, is that addiction makes people who suffer from it think and behave in a deviant way, particularly affecting their agency. It proposes that substance use is the underlying cause of this, as addiction is described as ‘a response to physical, psychological and social adaptations that occur after regular and/or excessive use of a psychoactive substance (or regular and excessive performance of behaviours) with non-functional and harmful consequences’, and where deregulation of brain activities is evident (GGZ Nederland, 2013, p. 15). The document goes on by stating that addiction is characterized by the loss of autonomy, for example the autonomy of free choice over continuing or stopping substance use. More serious effects, according to the document, include a persons’ behaviour and thinking being completely fixed on using substances, limiting social and psychological functioning. At the same time, it states that recovery is always possible and ‘many are able to change their behaviour and thus their addiction, for the most part without professional help’ (GGZ NL, 2013: p.17). In critical literature on the brain disease model of addiction, the high prevalence of ‘natural recovery’ (Granfield & Cloud, 2001), or recovery without professional help, is often presented as an argument that addiction is not a clinical brain disease (Heather et al., 2018). The Dutch practice-level policy is explicitly impartial about such understandings of addiction, stating that definitions of addiction as either a brain disease or a ‘cultural problem’ contain ‘a core of truth, but they fall short as a description of the problem’ (GGZ Nederland, 2013, p. 17).

Furthermore, the document states that it is crucial that any support aimed at resolving addiction should start ‘from an unconditional respect for the autonomy of the individual and from the fundamental insight that self-determination and free will are inherent in human existence’ (GGZ NL, 2013: p.17). The presentation of addicted persons as disordered subjects with affected agency (and a deregulated brain) on the one hand, but also in control, autonomous and self-determined on the other hand is also found elsewhere in recovery policy research. Fomiatti et al. (2017), for example, argue that various treatment philosophies, as well as medical and scientific knowledge, produce incoherencies about the nature of addiction and those defined as addicted. These symptom-focused and clinical problematizations of addiction are often criticized by the addiction recovery movement (Davidson & White, 2007). In the Netherlands, the national service user representative organization (Black Hole foundation) argues that clients in the addiction services should not be seen as an object of care, but instead as a subject of care (Black Hole foundation, 2015). Seeing clients as objects means seeing addiction services as the treatment of addiction symptoms first and foremost. However, seeing clients as subjects means seeing addiction services as offering service to autonomous individuals first and foremost, which may include treating symptoms of addiction.

Lastly, the practice-level addiction policy implicitly presents a structural and societal problem of addiction: stigma. The document states that many persons with addiction only seek help after long periods with problems or when they ‘get stuck’, after which recovery is more difficult. The cause of this is described as ‘denial, trivialization, taboo and shame’ (GGZ Nederland, 2013, p. 6). On one hand, these aspects are personal and concerned with individual behaviour, (lack of) personal insight, coping strategies, or self-stigma, but on the other hand, this is linked to public stigma and discrimination (Wakeman & Rich, 2018). There is no further discussion of stigma in the practice-level policy documents.

Recovery vision: proposed ‘solution’ to the problem of addiction

In the practice-level document (GGZ Nederland, 2013), the layering of the problem of addiction is highlighted, as addiction is presented as a problem of biological, psychological, social and cultural levels. Accordingly, the existence of many definitions of recovery is recognized. As such, four interrelated aspects of recovery, also described by van der Stel (2014), are assumed: clinical, personal, functional and societal recovery. The practice-level policy does not just problematize substance use and its consequences, but also problematizes personal and social issues that persons with addiction may encounter. Ultimately, the problem of addiction, according to practice-level policy, is about loss or lack of quality of life, wellbeing and autonomy.

Problematization of drug addiction by the forensic addiction services

Another practice-level sector concerned with drug addiction treatment in the Netherlands are the forensic addiction services. The main difference with regular addiction services is that forensic treatment programs are court-ordered and mandatory for their clients and are therefore always linked to a committed crime and a repressive criminal justice framework. However, forensic addiction service policy also tries to find solutions within that criminal justice framework to preserve autonomy and enhance people’s lives. The problem representation of drug addiction in the forensic addiction service sector can be described as pragmatic. The guiding principle is the effect that addiction has on (the risk of) criminal behaviour. In other words, drug addiction is a problem if the consequences lead to crime or recidivism.

“Abstinence is and remains the treatment goal to be pursued for every client, but the relationship between substance use and criminal behaviour is the starting point. If substance use is permissible within the treatment goals (and therefore the risk of recidivism is not increased), controlled use is acceptable.” (Expertise Center Forensic Psychiatry, 2020, p. 11, p. 11)

Problematized subjects are described broadly: any adult (18 years or older) client who uses substances with risk of criminal behaviour. This target group is described as often having other mental health problems as well, such as psychiatric disorders or intellectual disabilities. This comorbidity is highlighted as an important part of the problem of addiction. Because of the focus on crime risks, the presented problem is extended to any substance use or behaviour that is potentially related to crime, not just addiction. Furthermore, no distinction is made between hard drugs and cannabis, as is done in the governmental Dutch drug policy.

In the forensic addiction practice-level policy document, several leading underlying principles and models are described that can be applied simultaneously or whenever most appropriate: the What Works principles (or Risk-Need-Responsivity model) (Andrews & Bonta, 2010), the Good Lives model (Ward & Stewart, 2003), the recovery model (Anthony, 1993), the rehabilitation model (Pieters & Peuskens, 1995) and the biopsychosocial model (Engel, 1977). For the recovery model, the document refers to the model used in the practice-level document of addiction services (GGZ Nederland, 2013; van der Stel, 2014). These models, especially when applied together, address much more than substance use or addictive behaviours. The underlying assumption is that many aspects of life are related to addiction and crime and that recovery is more like a way of living than a clinical reduction of symptoms.

Discussion

In the analysis of government and practice-level policy we aimed to show how drug addiction is problematized in two types of policy that address drug addiction in the Netherlands. The goal was to understand how the recent adoption of addiction recovery in addiction services practice fits within the unchanged older governmental drug policy. In practice-level policy, recovery is the leading principle of addiction treatment and entails personal, clinical, societal and functional recovery. Without explicitly referring to the concept of addiction recovery in any of the governmental Dutch drug policy documents (including in the more recent ‘letters to parliament’), the national drug policy touches upon some elements of recovery nonetheless. The discussion of abstinence-based versus harm reduction approaches addresses clinical aspects of recovery. Furthermore, by recognizing the role that inequalities and social marginalization play in drug addictions and by appreciating the therapeutic effects of heroin-assisted treatment, societal and functional aspects are acknowledged. However, something similar to personal recovery, which particularly characterizes the recovery movement historically (Deegan, 1988; van der Stel, 2014), is lacking in the current governmental drug policy. Thus, whilst providing a nuanced and comprehensive problem representation of drug addiction, a crucial link with recovery in practice is currently lacking in the governmental policy.

The lack of recovery in national drug policy has not hindered the development of recovery-oriented practice-level policies in the Netherlands substantially. The Dutch recovery movement was able to gain ground and influence the mental health and addiction services bottom-up, without the need for a governmental program or policy vision (Bellaert et al., 2021). Consequently, the concept of recovery in practice-level addiction policy was less subject of political debate and interpretation in the Netherlands compared to other countries where the concept was introduced. In the US, UK and Australia, scholars and harm reduction advocates have criticized governmental recovery policy documents because they helped enforce conservative neoliberal values, making addiction recovery the responsibility of individuals, because they problematised all drug use, and because they coincided with budget cuts (Duke, 2013; Humphreys & Lembke, 2014; Lancaster et al., 2015). Perhaps more similar to the Netherlands, Irish political leaders and civil servants pragmatically avoided such debates between recovery advocates and their critics by initially using the term ‘rehabilitation’ rather than ‘recovery’ in the development of their drug policies (Mayock & Butler, 2021). In the Netherlands, addiction services consequently adopted a recovery vision that was less influenced by political debate and influenced more by developments in the broader mental health field, which in turn was influenced by lived experience advocates. An explanation may be that the long history of viewing drug addiction as a public health issue in the Netherlands, has made the introduction of recovery more like a continuing development of addiction services rather than a paradigm shift.

Even though the Dutch addiction service practice features recovery throughout, recovery is not adopted in government policy. A possible explanation is that governmental drug policies, that often originated from international conventions (such as the dominant United Nations conventions on Narcotic Drugs), primarily frame criminal justice and law enforcement, even in the Netherlands where drug policy is historically health orientated. Because addiction recovery principles do not strain the boundaries of these frameworks, there may be less urgency to change the Dutch drug policy. This is different for some harm reduction measures, for example. In the Netherlands, the tolerance policy for cannabis and the regulation of heroin-assisted treatment methods were included in governmental drug policy, because they require – contested (Csete & Grob, 2012) – interpretation of the international UN Conventions (United Nations, 1988; Single Convention on Narcotic Drugs, 1961, as Amended by the 1972 Protocol Amending the Single Convention on Narcotic Drugs, 1961). In the case of recovery, such international standards are not hindering implementation. Inclusion of recovery principles in drug policy may therefore be less pressing.

Lastly, one of the goals of our policy analysis was to consider the impact of policies on recovery experiences of individuals, as stated in question five from the WPR approach (‘What effects are produced by this representation of the problem?’ see also Table 1). In the Netherlands, the wish to develop recovery-oriented addiction services emerged from (ex-)service users (Charter of Maastricht, 2010). A more equal relationship between service user and provider and stigmatization were important drivers for the Dutch recovery movement. As we have shown in the current paper, patient emancipation and stigma are both addressed in the problematization of drug addiction in the practice-level documents, but not in the governmental drug policy. This may mean that the problematization of drug addiction in governmental drug policy produces negative effects for people with drug addiction, as it does not address patient emancipation and stigma. Stigma in particular represents one of the biggest barriers to recovery (Room, 2005; van Weeghel, van Zelst, Boertien, & Hasson-Ohayon, 2019). Recovery principles, as proposed in the Dutch practice-level policy, represent a wellbeing and strength-based approach to addiction which views persons with drug addiction as a heterogenous group of autonomous individuals who are more than their condition and who can recover. If government drug policy would also embrace such principles and introduce more consistency in the problematization of drug addiction (opposed to the current poldering), it may also positively contribute to patient emancipation and public destigmatization.

Governmental drug policy has allowed room for practice-level recovery policies to develop. However, some practical barriers for this development are also described (Bellaert et al., 2021). Structural implementation of recovery-oriented practices was hindered by the rigid and fragmented financial structures in the Netherlands, in which social support comes from municipal budgets, whilst clinical care is provided through health insurance, for example. In practice, this means that implementation of recovery-oriented practices is still mostly pilot- and project-based, primarily operationalized through employment of experiential peer experts (Bellaert et al., 2021). Thus, for individuals with drug addiction, this means that recovery-oriented support, as it is conceptualised in the practice-level addiction policy documents, is not fully available.

Limitations

There are some limitations to this study that merit mention. Firstly, there may have been selection bias regarding the documents that we analysed for this study. Whilst the Dutch drug policy white paper used in this study is not the most recent governmental drug policy publication, it is the most recent comprehensive document and, moreover, still reflects the current policy. We also scrutinized more recent governmental documents for potential relevance to this study but discovered no significant changes in drug policy. Furthermore, some private addiction services are not part of the national association that published the practice-level policy documents. However, these private services represent only a small part of addiction services in the Netherlands. Finally, the WPR approach is not concerned with addressing how policy problems unfold in practice (Clarke, 2019). Next to discourse, other factors, such as particular actors, also shape policy development. This would require other forms of data collection and analyses, such as situated practices as described by Rabinow (2009).

Concluding Thoughts

In this paper we analysed how drug addiction is problematized in two distinct types of policy using Bacchi’s What’s the Problem Represented to be (WPR) approach. We argued that both government-level and practice-level policies apply divisive practices to produce a particular problem of drug addiction. Firstly, government drug policy mainly problematizes the nuisance to communities caused by people that use hard drugs and their health problems, particularly emphasizing that the harm is related to the type of drug that people use. The proposed solution is a focus from law enforcement and harm reduction services on particular groups of people with drug addiction. Secondly, practice-level policy problematizes the negative impact of addiction on a person’s agency, wellbeing and surroundings, regardless of the type of substance or addiction, and distinguishes levels of severity of the impact of addiction. Here, the proposed solution is to organise the intensity of treatment and support around the needs of the person with drug addiction.

We compare the two types of Dutch policies discussed in this paper regarding their problematization of drug addiction, however, the dates on which they appeared are far apart. The Dutch drug policy document is 26 years old, whilst the practice-level document is more recent (2013). Since the addiction recovery approach is relatively recent, especially in the Netherlands, it makes sense that this is not included explicitly in the older drug policy document and the developments in practice-level policy may also represent a historical development regarding views of drug addiction which the Dutch government has simply not consolidated in a new drug policy yet. As we have shown in the problem analyses, the comprehensive and nuanced Dutch drug policy partly overlaps with and leaves room for a recovery-oriented approach to drug addiction, regardless of whether it mentions recovery explicitly. Still, it could raise the question whether it is time to update the Dutch drug policy. A recent ‘manifest for a realistic drug policy’ published and signed by prominent Dutch drug scholars, treatment specialists and (former) politicians (Bakkum, Bergkamp, Groothuizen, & Nabben, 2020) suggested to do so. Reasons for the update included substantive issues such as regulation of illicit drugs, and formal issues such as the age and lack of scientific base of the current drug policy. The misalignment of how drug addiction is addressed in governmental drug policy and practice-level policy is not mentioned in the manifest but could be another reason for updating the Dutch drug policy, as treatment providers experience some practical barriers to provide recovery-oriented support (Bellaert et al., 2021).

Whilst both types of policy in this study address drug addiction, they have fundamentally different starting points. Governmental policy deals with large societal issues, including crime, international relations, law enforcement, public health and prevention, whilst practice-level policies deal primarily with treatment, prevention and public stigma (see also Figure 1). Thus, that these types of policies present the problem of drug addiction differently may not be surprising. However, it is notable that in the Netherlands, the practice-level policy developed independently from government policy to a large extent. Despite different priorities and problematizations of drug addiction, it seems that the comprehensiveness of the Dutch governmental drug policy, partly as a result of the pragmatic polder model, ensures that conceptually, both types of policies can co-exist without strain. Moreover, the independent development may also be the reason that addiction services were able to incorporate a vision on addiction recovery that was less subject to political debate as it was in other countries where it was adopted earlier (Duke, 2013; Lancaster et al., 2015). The Dutch recovery movement did not need the government or political parties to get a foot in the door. Nevertheless, practical limitations and barriers for implementation and execution of recovery-oriented practices still exist, which may be the result of that same lack of government involvement (Bellaert et al., 2021).

In conclusion, integrating recovery in governmental drug policy may have benefits, as it can help reduce stigmatization of individuals with drug addiction and lay the ground for a structural implementation of recovery-oriented addiction services. However, governmental adoption of recovery may also have the unwanted effect of enforcing certain political values upon the conceptualisation of addiction recovery, and of causing ideological and organisational conflict, an effect that the Dutch practice-level sector has been able to avoid so far. This delicate situation of constructive ambiguity is important to consider if one attempts to integrate these two visions of how to handle drug addiction.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This research was supported by the European Research Area Network on Illicit Drugs (ERANID). It is funded in the Netherlands by The Netherlands Organisation for Health Research and Development (ZonMW), (63200000105) and in Belgium by the Research Foundation Flanders (FWO, Belgium) and the Belgian Science Policy Office (BELSPO).

ORCID iD

Thomas F. Martinelli

Notes

Author Biographies

Thomas Martinelli works as a researcher and PhD candidate at IVO Research Institute. He graduated in Cultural Anthropology (2010) and International Criminology (2013) and has developed ample experience with doing qualitative and quantitative research. He started as a freelance researcher after his studies and works at the IVO institute since 2016. At IVO his research focuses on people in vulnerable situations, including sexworkers, people who use drugs, people in prison with disorders, and homeless people. Currently he is also working as a PhD candidate on an international study on recovery from drug addiction. In 2019 he helped evaluate the EU Drug Strategy and Action Plan (2013-2020) with ICF. From 2019 to 2021 he worked with the Maastricht University to study the gateway effect of e-cigarette use to combustible tobacco use among high school students.

Prof. Freya Vander Laenen is senior lecturer at Ghent University, Department of Criminology, Penal law and Social Law. She is a co-director of the multidisciplinary research group ‘Institute for International Research on Criminal Policy’ (IRCP). Her expertise focuses on vulnerable individuals (because of substance use, mental illness, and/or social exclusion) in contact with the criminal justice system. She has acquired many years of experience as a (co-)supervisor in interdisciplinary research on drug policy, offender rehabilitation and recovery. She is also (co-)promotor of several on-going PhD projects. As a promotor, she was part of the Geconcerteerde Onderzoeksactie (GOA) titled “Developing multidisciplinary strengths-based strategies for mentally ill offenders” – an interdisciplinary initiative from the faculties of Law and Criminology, Medicine and Health Sciences, and Psychology and Educational Sciences. Freya Vander Laenen is a member of the interfaculty Ghent University Research Consortium Crime, Criminology and Criminal Policy (IDC CCCP). This consortium facilitates and encourages amongst others research in the area of offending, desistance and recovery. She is a member of various international networks, like the European Society of Criminology and the International Society for the Study of Drug Policy.

Prof. Gera Nagelhout works as Chief Science Officer at IVO Research Institute and as endowed professor at Maastricht University (research school CAPHRI) in the Netherlands. Her research projects focus on health, wellbeing, and addiction among people with a lower socioeconomic position. She is supervising several PhD students on different projects related to smoking cessation, mentoring vulnerable youth, and recovery from drug addiction. She graduated in 2007 for the study Communication Science with the specialization Health Promotion and Government Communication. In 2012, she received cum laude for her PhD thesis on the impact of smoking bans on smokers and also the Dutch Public Health Prize. In 2017, she received the ECL ECToH Young Professional Award. And in 2019, she received a Societal Impact Award with one of her research teams. In the past, she has worked for Radboud University Nijmegen's IQ Scientific Institute for Quality of Healthcare, STIVORO Dutch Expert Centre on Tobacco Control, the Dutch Alliance for a Smokefree Society, and the study program Nutrition and Dietetics of the Hague University of Applied Sciences.

Prof. dr. Dike van de Mheen studied Health Sciences until 1987. Her PhD thesis about “Socio-economic health differences during the life-course” was successfully defended in 1998. From 1987-1988 she worked as researcher with the Rotterdam Area Health Authority. This was followed by an appointment as researcher and assistant professor at the Erasmus University Rotterdam (Department of Public Health) from 1988 until 1999. During 1998 and 1999 she was senior adviser at the Rotterdam Area Health Authority. From 1999 until 2017 she was Director of Research and Education at the IVO Addiction Research Institute Rotterdam. She has extended experience in research (both quantitative and qualitative) on drug and alcohol related issues. Since April 2007 until September 2017 she was professor “Addiction Research” at the Erasmus University in Rotterdam. From 2012-2016 she was also professor “Care and prevention of risky behaviour and addiction” at Maastricht University. Starting december 2016 she is Professor Transformations in Care and head of the Department Tranzo, Scientific Center for Care and Welbeing, School of Social and Behavioral Sciences, Tilburg University.

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