An aim of the ‘disease model’ of addiction is to imply that people who use drugs are not to blame, thus undermining stigma. But the implication of diminished agency can also increase stigma, and conflict with the therapeutic value of taking responsibility for one’s actions. Hanna Pickard has argued that for addiction clinicians, this results in a tension between reducing clients’ experiences of stigma and blame, and encouraging their capacity to change by holding them accountable. She describes this as the ’blame/rescue trap’: The clinician either ‘rescues’ the client from blame by presenting addiction as involving loss of control, or claims clients are agents – and thus to blame.
Limited research has explored how addiction clinicians typically experience or manage this tension. To address that gap we interviewed nine clinicians from diverse professional backgrounds and settings in Victoria, Australia. Thematic analysis was undertaken by all authors. Major themes were: (1) Interprofessional and internalised stigma, where judgment from professionals and self-judgement hinder client engagement; (2) Structural stigma, including limited funding, workforce shortages, geographic inequities, and fragmented services; and (3) Challenges within the therapeutic alliance.
Draw on these results we argue that while Pickard’s nuanced analysis is useful at the level of individual clinicians, it omits important ways practice is influenced by factors beyond the therapeutic relationship. The clinical encounter in addiction treatment needs to be understood in the context of broader impacts of stigma on clients’ therapeutic experience.