When Help Becomes a System
Reflections on Medication-Assisted Rehabilitation, Dignity, and the Vulnerable Human Being
There are people who carry their entire life story in the way they sit down in a chair.
I learned this early in social work.
Some entered the office with quick movements and a hard voice, as if they constantly had to defend themselves against something invisible. Others sat at the very edge of the chair, their eyes fixed on the floor. Many had learned to read a room before speaking. They already knew how people looked at them.
Drug addicts.
Methadone patients.
Failures.
Words that slowly began to shape the way a person understood themselves.
Behind those words were lives. Lives often marked by violence, shame, loneliness, and loss. But also lives marked by humor, endurance, and an almost unimaginable capacity to survive.
This essay grows out of the research article “Being a Useful Puppet”, written together with Mona Jerndahl Fineide and Ulf Dahl, on experiences with municipal medication-assisted rehabilitation in Norway. The study explored how municipal social workers and general practitioners experienced the Norwegian MAR system. Yet beneath the questions of organization, collaboration, and treatment lay something deeper:
What happens to a human being when help gradually becomes a system?
The Good Intention
When medication-assisted rehabilitation was expanded in Norway, the intention was humane and necessary. Many opioid users were living under brutal conditions. Overdoses, illness, crime, and social exclusion shaped everyday life. Methadone and later Subutex/Suboxone represented, for many, a possibility of survival.
And for some, that is exactly what happened.
A new life slowly began to emerge.
One person found stable housing.
Another reconnected with their children.
Someone no longer woke each morning with heroin as the first thought of the day.
It would be deeply unfair to ignore this.
Medication-assisted rehabilitation saved lives.
Yet at the same time, another experience emerged among many professionals working closely within the field. A growing unease. A sense that something essential was slowly being lost.
Because human beings need more than medical stabilization.
They need meaning.
Belonging.
Dignity.
When Diagnosis Becomes Identity
Modern healthcare depends on diagnoses. Diagnoses provide access to treatment, rights, and support. They make suffering intelligible.
But diagnoses can also become identities.
In our article, we described how the medical understanding of addiction had gained an increasingly dominant position. Addiction became understood primarily as disease. In many ways, this was a significant moral advance. Condemnation and moral judgment could be replaced by treatment and care.
Yet a paradox emerged.
If a person is understood primarily as chronically ill, hope itself may begin to weaken.
Over the years, I met individuals who gradually lost the ability to describe themselves in any language other than diagnosis.
“I am an addict.”
“I am a methadone patient.”
“I am damaged.”
The words settled into the soul.
The Danish philosopher Svend Brinkmann has written about how modern societies increasingly transform human struggles into medical conditions. Sometimes this is necessary and compassionate. Yet it may also lead people to lose the experience of being agents in their own lives.
This is a dangerous form of passivity.
Not because addiction lacks suffering. Quite the opposite. But because a human being can never fully be understood only through illness.
A person is always more than a diagnosis.
Shame
Addiction is deeply connected to shame.
Not only society’s shame, but the quiet inner shame.
The shame that settles into the body.
Into the voice.
Into the eyes.
Erving Goffman described stigma as a process through which people are gradually reduced to a single negative characteristic. When this happens, the rest of the human being becomes difficult to see.
I remember a man I met many years ago. He was known as difficult. Many professionals dreaded conversations with him. He could become aggressive when he felt cornered.
One day he entered my office quietly, holding an old photograph.
It showed him together with his daughter when she was little.
“She doesn’t want to see me anymore,” he said.
Then silence filled the room.
In moments like that, categories collapse.
You no longer see “the addict.”
You see a human being grieving.
Perhaps this is what shame ultimately destroys: the belief that one can still be seen as fully human.
The Language of Control
Every helping system contains elements of control.
That is unavoidable. Society must manage medications responsibly. Rules and structures are necessary. Urine tests, agreements, and procedures all have their place.
But control has its own language.
And when this language becomes dominant, something happens to the relationship between human beings.
In our study, several professionals described how the medical and controlling aspects of the MAR system had become too dominant. Questions of life mastery, relationships, and rehabilitation were given less attention.
This is not merely an organizational problem.
It is also a human problem.
Because what kinds of questions begin to dominate when control takes over?
Did you take your medication?
Did you provide the urine sample?
Did you follow the rules?
All these questions may be necessary.
But they are not enough.
Martin Buber once wrote that human beings can encounter one another either as a “Thou” or as an “It.” When a person becomes primarily an object of monitoring and administration, something of their humanity begins to disappear.
The person becomes a case.
A file.
A treatment trajectory.
And perhaps this is where many helpers experience their own discomfort. Not because they lack compassion, but because they begin to sense how systems slowly shape their own way of seeing.
In our study, some physicians described themselves as “useful puppets” within the system.
It is a phrase filled with exhaustion.
As though the helper, too, is gradually losing something of themselves.
Loneliness
One of the most striking aspects of the research was the degree of loneliness surrounding this field.
Many MAR users continued to live deeply isolated lives, even after years of treatment. The drug use might be reduced, but the loneliness remained.
There are forms of loneliness that do not disappear simply because the body becomes stable.
The loneliness of lost years.
Lost relationships.
Lost possibilities.
But the helpers, too, often stood alone.
Many general practitioners had only one or a few MAR patients. They frequently lacked strong professional communities around them, while simultaneously carrying responsibility for highly complex human situations:
Addiction.
Trauma.
Mental illness.
Aggression.
Despair.
Hope.
All at once.
No profession can carry this alone.
The Paradox of Normalization
The MAR system also carried an ideal of normalization. Patients were meant to use ordinary healthcare services and live as ordinary citizens.
The intention was deeply humane.
But normalization is far more difficult than it sounds.
What does a “normal life” actually mean for someone who has lived for years in exclusion and instability?
Sometimes the very ideal of normalization becomes another burden.
The person is expected to function like everyone else while still carrying shame, anxiety, trauma, and social vulnerability.
Then failure can feel even heavier.
Practical philosophy reminds us of something essential here:
Human lives can never be fully standardized.
No procedure can completely grasp the complexity of a human being.
Dignity
During many years in social work, I learned that dignity rarely appears in grand gestures.
More often, dignity exists in small moments.
In the way a person is greeted.
In a voice that does not condemn.
In silence that can tolerate pain without turning away.
Sometimes I think modern systems underestimate the importance of such moments. We speak endlessly about treatment, methods, and evidence. All of this matters. But human beings do not live by treatment alone.
They also live by the experience of being meaningful to someone.
A person can survive for a long time on very little hope if they still feel seen.
The Vulnerable Human Being
Perhaps this is what the entire discussion about medication-assisted rehabilitation ultimately comes down to:
How do we understand the vulnerable human being?
Is a person primarily the sum of their problems?
Or does something remain within the human being that cannot be reduced to diagnosis, records, or systems?
Hannah Arendt once wrote that every human being carries the possibility of a new beginning. I believe this is crucial also in the field of addiction.
Not because every story ends well.
Many do not.
But because the possibility of human transformation must never completely disappear.
A society that loses this hope also begins to lose something of its own humanity.
Being Seen Again
I have often thought that true rehabilitation may begin in a surprisingly quiet moment.
Not necessarily when the medication works.
Not when the paperwork is completed.
But in the moment a person experiences that someone still sees more than the problems.
Someone who sees the human being behind the stigma.
Behind the diagnosis.
Behind the shame.
Because people often change in response to how they are seen.
Not quickly.
Not easily.
But sometimes something essential happens when a human being is no longer treated merely as a problem to be managed.
Perhaps this is where practical philosophy truly begins.
In the attempt to hold on to the human being even as the systems around us grow larger and more powerful.
Closing Reflection
When we wrote the research article on medication-assisted rehabilitation, it appeared on the surface to concern organization, collaboration, and professional roles.
But beneath all this lay another question.
A quieter question.
How do we meet human beings who have lived for a long time outside the fellowship of society?
No guideline can fully answer that question.
Because in the end, it is determined not only by systems.
But by our gaze.
Our language.
Our patience.
And perhaps most of all by whether we still believe that a human being is more than what life has done to them.
References
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Pettersen, K.T,, Mona Jerndahl Fineide, and Ulf Dahl (2014); Being a Useful Puppet. Social Work and Social Science Review, 17(2), 212-225.
Waal, H., Brekke, M., Clausen, T., Lindbæk, M., Rosta, J., Skeie, I., & Aasland, O. G. (2012). General practitioners’ views on medication-assisted rehabilitation. Tidsskrift for Den norske legeforening, 132, 1861–1866.
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How do we meet human beings who have lived for a long time outside the fellowship of society?
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