The American Society of Addiction Medicine characterizes addiction as a “primary, chronic disease of brain reward, motivation, memory and related circuitry.” The National Institute on Drug Abuse defines addiction as a ‘chronic, relapsing brain disease” that changes the structure and functionality of the brain. So why do so many people still think of addiction as a moral failing? Why do they still refer to victims of substance misuse disorders as meth freaks, alcoholics, junkies, crackheads and garden-variety drunks?
The answer is simple as it is depressing: because that’s the way it’s always been. Addicts are scorned by communities and celebrities with addictions are exploited or hounded by paparazzi. And while the government purports to view addiction as a disease, it often works in opposition to that position through the “War on Drugs,” which counts most drug users as criminals. Even those of us in the treatment community still—consciously or unconsciously—employ stigmatizing programming and language—such as when we focus on “dirty” urine.
So despite widespread agreement that addiction is best understood as a complicated behavioral-biological scenario that requires treatment, the system is hard-wired to prolong stigmatization, and stigma contributes to addiction's lethality.
Of course, there is a long history of mental illness being misunderstood and stigmatized, from the “schizophrenigenic mother” to the warehousing of “crazies” in state hospitals or prisons, which was beautifully captured by the director Lucy Winer in her recent highly-acclaimed documentary, Kings Park. Addiction and mental health problems are still spoken of in hushed tones, and patients and their families are still blamed.
The idea that those with addictive disorders are weak, deserving of their fate and less worthy of care is so inextricably tied to our zeitgeist that it’s impossible to separate addiction from shame and guilt. Addiction comes with a second punch in the gut: the burden of being treated like a second-class citizen and expected to act accordingly. Stigma impacts us all, both consciously and unconsciously, and is perhaps the single largest contributor to the mortality rate. Consider these eight points:
1. People fail to seek treatment.
Most people who struggle with an addictive disorder fail to seek treatment, in part because of their concern that they will be labeled an “addict” and that the stigma will stick. If you ask the question, “Would you rather go to treatment or die?”, presumably nobody would choose death, but that’s how it often goes (Kurt Cobain, who never sought treatment, is a tragic example). Often, a crisis precipitates treatment, so the problem is already well-advanced. If we removed the stigma, guilt and shame from the equation, people would find it easier to make a realistic, objective assessment of their substance misuse and discuss it openly with a health care provider.
2. The medical profession fail to treat addicts properly.
Can you think of other situations in which the health care system abdicated responsibility for dealing with a health care issue that afflicts such a huge segment of the population? For far too long, those people who did seek treatment, often following a crisis, found no appropriate reception from the medical community. Doctors were slow to recognize addiction as treatable, and so patients were encouraged to find help outside of the medical community, in 12-step programs that based on non-scientific practices, normally anathema to physicians. 12-step programs helped many, but those that did not succeed there found themselves in the unenviable position of having been directed to a place by their doctor, having the recommended solution ineffective and being reluctant to return to their physician for further help. A better paradigm? The medical community should recognize unhealthy, addictive behavior as part of its purview and would apply evidence-based approaches in their practices.
3. The mental health profession ostracizes people with addictive disorders.
It is routine in mental health practice for persons with substance misuse problems to be discharged from treatment when substance misuse is revealed. They’re told that the drinking or drug use renders them “unavailable” for the work of psychotherapy and that they need to “get clean” first by going to a chemical dependency or substance abuse treatment program. They are told that whatever issues seem pressing and paramount to them are “just the drugs talking”. It’s common for clinicians to believe that before they can help a patient with the various traumas, interpersonal conflicts, intrapsychic issues and other problems that other people are helped with in psychotherapy (and which are, of course, related to their their use of substances) the patient needs to first become abstinent from substances. Many patients who are sent to traditional drug treatment programs that are abstinence-focused end up neither “clean and sober” nor receiving good psychotherapy. How might things be different? In many cases, the use or misuse of substances by patients in psychotherapy would be managed as part of the clinical constellation of issues and symptoms that are being treated.
4. Funding for addiction treatment is discriminatory.
In spite of the huge impact and cost of addictive disorders on society, the way that addiction treatment is funded is disproportionately low. Despite passage of Federal Mental Health Parity legislation, mental health and substance use disorders continue to be treated differently—and often poorly—compared to “medical” illnesses. Some coverage appears co-equal on paper, but frequently the coverage that's allowed is not authorized, leaving people without the treatment for them to meet their goals. What if there was no stigma in addiction? Given its huge cost to society, addiction should be funded and paid for on a level playing field with medical problems.
5. Addicts get sent to jail.
Where substances are concerned, people go to jail for the possession of something that is part and parcel of their addiction, unlike the diabetic caught walking out of Costco with a shopping cart full of Ring Dings. Most of the money that governments spend on “drug control” is spent on criminal justice interdiction rather than treatment and prevention. Here again, clearly, is a system with stigmatization at its roots: blaming, punishing and making moral judgements instead of providing treatment and other help that would change behavior. The more of a stigmatizing stance one takes towards substance misuse the more likely one is to support criminalization of drug offenses and the less likely is to support insurance coverage and treatment for drug addiction. Taking the stigma out of addiction argues for prevention and treatment as opposed to prosecution and incarceration.
6. Even when people do get to treatment, stigmatization can continue and contribute to poor treatment outcomes.
It is critical to recovery that treatment programs not send messages to patients that are blaming (for relapse) and shaming (for being weak). People enter treatment at a vulnerable moment, psychologically and in terms of their brain chemistry. Addiction comes with a hard-to-escape sense of failure that recapitulates prior disappointments and works in opposition to growth. Patients have spent a lifetime trying to silence the “inner critic” that repeats "I'm-not-good-enough" messages, so it's critical that the culture and language of treatment provide a healthy soil in which patients can grow seeds of hope that are vital to recovery. In an optimal treatment setting, patients aren't expected to play the role of one-who-should-be-ashamed. Instead, they are intrinsically involved in planning their own treatment, helping to choose the goals and techniques of treatment.
7. People in recovery are always under suspicion.
When people obtain a stable recovery they are always presumed to be on the verge of relapse. The label, shame and stigma of problems with substances is always around—once an addict, always an addict. This has an enormous impact on their lives every day—in the community, in the family, in social networks. The person in recovery has their autonomy and their ability to participate in the normal, character building aspects of family life constantly in question. The stigma of addiction is built in to foundational aspects of society, especially those in social networks that are necessary for people to rebuilt their lives. What if there were no stigma in addiction? The “addict” role would not last a lifetime.
8. They confront stigma-based roadblocks constantly.
The cancer survivor is proud, but those in recovery from addiction face ongoing stigma and discrimination instead. People in recovery are faced with obstacles, especially those who have been in treatment or in the criminal justice system for chemical dependency. Employment, education, insurance and the ability to vote are all fraught with uncertainty and discrimination for those in recovery. People in recovery have a harder time finding and keeping jobs, getting licenses, food stamps, benefits that help their children. In other words, important aspects of living that are so critical to a stable recovery for persons who have been treated for addiction, such as employment, housing and providing for one’s family are that much harder to get. Things need to change. Having struggled with addiction in the past should not make life that much more difficult now.