It’s said again and again that we must accept the disease theory of addiction to reduce stigma.  If only everyone would discard the belief that addiction has anything to do with choice, then addicts and alcoholics could stop feeling ashamed of their problem and get help.  In fact, for the better part of the last century, this emotional argument seemed to be the entire case for the disease model of addiction, proof and/or a cogent argument was never offered, we were just told that we needed to accept that substance abuse was the product of a mysterious disease, or we were evil, uncaring, heartless, judgmental people.  Has it worked?

The Counterproductive Movement Towards Destigmatization

The UK Mail mail just reported on a new study of public attitudes toward addicts:

Some 43 per cent said they would not want to live next door to a former addict. Just 41 per cent said they would be willing to work with former addicts.

And one in three said anyone thinking about entering a serious relationship with a former addict would be ‘foolish’, even if the addict had recovered fully.

More than half said they would not trust a recovered addict to act as a babysitter

The authors contend that more needs to be done to break the stigma.  They blame terms like “junkie”, and outdated perceptions of mental illness for the stigma.  Meanwhile, here in the states, a report released in the November issue of the Journal of Psychiatry also shows that addiction comes with a high amount of stigma.  The researchers and press are baffled because in the same period when acceptance of addiction as a brain disease has risen, stigma has remained relatively unchanged.  As the researchers say:

More of the public embraces a neurobiological understanding of mental illness. This view translates into support for services but not into a decrease in stigma. Reconfiguring stigma reduction strategies may require providers and advocates to shift to an emphasis on competence and inclusion.

The study compares survey data for 1996 and 2006, over this time period public acceptance of addiction as a neurobiological condition increased 9 points, the number of people who see it as a chemical imbalance also rose by 9 percentage points, and the number of people who see addiction as genetically caused rose by 10 points.  The same study shows that the number of people who would be comfortable with an addict as a neighbor went down by 5 points, that less people would want to socialize with an addict, and the other stigma measures remained relatively unchanged compared to the great gains in acceptance of the disease view of addiction.  Essentially more and more people are coming to accept addiction as a disease, but this isn’t putting a dent in the stigma, which is getting worse in some ways.  Why is this?

The Disease Model of Addiction Stigmatizes Substance Users As Doomed To Remain Addicted or Relapse

Personally, I couldn’t think of a better way to stigmatize a substance user than by convincing everyone that he is fundamentally incapable of controlling himself, that he is diseased, and that he will continue to have addiction for the rest of his life.  Who wants to live next door to a ticking time bomb who will relapse at any given moment?  I don’t want to live next to that.  So in promoting the view that the addict’s free will is hijacked by the disease of addiction, and that this is their fate at a genetic level, the disease proponents may actually be creating more stigma, they may be acting in a way that is counterproductive to their own stated goal of reducing stigma.

I’ve known many people who have found it hard to escape the shadow of their past with addiction, but I have personally not found much resistance in my own life.  I’ve been completely open about my past, and while this may have closed a few doors, I have found several (non recovery related) internships and office jobs where I was swiftly and literally given the keys to the office and trusted fully, even though the employers knew of my checkered past.  I think I’ve gained this acceptance because of my openness, but more importantly because I FULLY accept responsibility for my past.  I readily acknowledge that I behaved quite irrationally, I did make very bad choices, and that no-one was to blame except for me, but that I learned from this and worked hard to change and leave that behavior in the past.  Now, for the record, I’m not advocating that anyone go spill the beans about their past with addiction, that’s an extremely personal choice dependent on context – I’m just saying that in my life as a former “addict” who rejects all the modern tenets of the recovery culture and fully takes responsibility for both his “addiction” and “recovery”, I’ve noticed a positive reaction to my attitude and take on things, and I haven’t felt stigmatized at all.

Have We Really Accepted The No-Fault Disease Model of Addiction?

I think that even though the public has generally accepted addiction as a medical disease (80-90% of americans believe it’s a disease by most estimates), they still recognize the concept as absurd on some base level, as evidenced by the public reaction to East Providence Mayor Bruce Rogers, who was recently ousted when news of rather minor check fraud charges from 16 years ago came to light.  The Mayor claims he is recovered, and that he didn’t realize these charges were outstanding, and I believe that (and in my opinion, I think he was shafted here, but that’s another discussion for another day), but then he showed an attitude which evoked a very angry response from many people when he stated in a press conference that:

“The American Medical Association says that addiction is an illness,” he said. “Mr. Conley evidently has no tolerance for people who are recovering from a serious illness. All offenses and accusations are not only 16 or more years old, but are all related to the illness.”

and:

“I had a drug addiction,” he said, “an illness, an illness which caused great problems in my life, to my family and to my friends. As a direct result of this illness, the [incidents] listed by Councilman Conley did occur.”

The comments entered on various news stories quoting Rogers’ press conference are merciless.  Something about excusing your bad choices with the disease of addiction really rubs people the wrong way on a gut level.  Besides constantly blaming his illness, there’s a subtle clue that he accepts no responsibility for his actions – when he says “the incidents…..did occur”.  What a bunch of nonsense, the incidents didn’t just occur – they were crafted and carried out by you, Mr Rogers.  If you’re wondering why people are so intolerant of your past, it’s your refusal to acknowledge your own role in these “occurrences”.  Notice he didn’t claim ignorance that he was passing bad checks, he just doesn’t claim any responsibility.  This kind of thing leads to these reactions:

He wants to compare himself to people with real illnesses. I”m sure cancer patients snorted cancer cells up their noses.

So you bounced checks and you are an addict Rogers and you paid back what you owed. Would you have paid this back if someone didn’t post this on Projo? How about the interest on these unpaid checks?

Crocodile tears-give me a break.

People really want substance users to take responsibility for any harms they cause, and I suspect we’d reduce unnecessary stigma if instead of showcasing victimhood, we showed the world “addicts” who accept responsibility for their behavior, and work to change and reject their former lifestyle.

Good Stigma?

There is a place for stigma according to some reasonable advocates of harm reduction, and researchers such as Stanton Peele who have shown that some cultures who teach responsible drinking while stigmatizing disorderly drunken behavior, even to the point of shunning those who do so, have had extremely low incidences of problematic drinking within their communities.  Peele offers up well documented studies of isolated Jewish and Chinese communities in his book 7 Tools To Beat Addiction, where rates of problematic drinking are far far below rates within the general population.These communities rightly stigmatized bad behavior, not necessarily the substance use itself. This makes sense, I think bad behavior while drinking should be stigmatized, and we should embrace those who admit their wrongs and work to rectify them. Instead, we’ve decided to try to fully destigmatize problematic substance use with the made-up excuse of an imaginary disease, and embraced the act of claiming victimhood – a practice which only causes people to continue problematic substance use by teaching them to feel powerless.  It does no good to promote as a role model, people who after 20 years sober claim that they are only an arm’s length away from a full alcoholic breakdown.  It does no good for people who want to change, and it does no good for those who have changed yet still face suspicion and distrust from people who have been convinced that this is true: “once an addict, always an addict”.*

Citations:

Am J Psychiatry. 2010 Nov;167(11):1321-30. Epub 2010 Sep 15. “A disease like any other”? A decade of change in public reactions to schizophrenia, depression, and alcohol dependence.  Pescosolido BA, Martin JK, Long JS, Medina TR, Phelan JC, Link BG.

Half of us don’t want ex-addicts next door: ‘Junkie’ stigma is ruining their lives, says report. By JACK DOYLE

*(Note from author, July 2016 – I edited the last paragraph under the heading “Good Stigma.” The original version of this article used the term “substance abuse” here, and that term didn’t fully accurately communicate the stigma in these communities. So I replaced “substance abuse” with terms like problematic drinking, and references to bad behavior while drinking. I don’t endorse stigmatizing substance use itself in any form, only the substance use related bad behaviors – like passing bad checks to fund a drug habit, or getting aggressive while drunk. I also changed any mention of substance abuse to substance use, as I am now rejecting this term as too vague and suggestive of ideas I don’t hold. – Steven)

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