From the Blog of Dr. Nora Volkow, Executive Director Original Date November 8, 2021
Far too often, shame and stigma fuel addiction and prevent treatment, argues Nora Volkow, MD, director of the National Institute on Drug Abuse. But replacing judgment with compassion can save lives.
Science has shed much light on addiction. We now understand that changes in brain networks needed for self-regulation cause substance use to become compulsive in some individuals — despite their best efforts to decrease or stop use. We are also gaining an understanding of the genetic, developmental, and environmental factors that cause susceptibility to drug experimentation and to the brain changes underlying addiction. For instance, data from a large longitudinal study of adolescents funded by the National Institute on Drug Abuse in close partnership with other National Institutes of Health entities have provided insights into the adverse effects of poverty and adversity on the developing brain, including neurobiological changes that make drug use and addiction more likely.
On the positive side, prevention research shows that providing targeted interventions to families with low incomes or lacking social supports can avert — or even reverse — these neurobiological changes. What’s more, decades of research on brain signaling systems have demonstrated that even once addiction takes hold, it is still reversible and recovery is achievable. Unfortunately, stigma limits the impact of this knowledge and the reach of our tools.
The Role of Stigma
Stigma pervades medicine, policy, and communities. Medical schools until recently offered little or no training in screening for or treating substance use disorders because, for many years, addiction was not seen as a medical problem. Even now, when medical systems offer treatment, it may be limited or inadequate. Among dedicated addiction treatment programs, fewer than half offer medications, which is tantamount to denial of appropriate, according to a National Academies of Sciences, Engineering, and Medicine report.
Insurers are often reluctant to cover addiction treatment, including medications for opioid use disorder, and coverage is limited when it is provided. Inadequate coverage puts these life-saving treatments out of reach for many people who need them. Stigma also prevents the use of medications in most justice settings—even though at least half of incarcerated individuals in the United States have a substance use disorder, often an opioid use disorder. What’s more, many communities fail to provide harm-reduction measures, such as syringe services programs and the overdose medication naloxone, out of a moralistic—as well as factually incorrect—belief that those measures encourage illegal drug use.
Even when treatments and other supports are available, people with addiction may not seek them, fearing the judgments of those around them and the discrimination they routinely experience in the health care system. Patients are often hesitant to disclose their substance use to their physicians. This contributes to the tragic reality that fewer than 13% of people with an illicit drug use disorder received any treatment for their addiction in 2019 and just 18% of people with opioid use disorder received one of the three safe, effective, and potentially lifesaving medications that could facilitate their recovery. The proportion of people with alcohol addiction who received medications is even lower: 3%.
Government policies, including criminal justice measures, often reflect — and contribute to — stigma. When we penalize people who use drugs because of an addiction, we suggest that their use is a character flaw rather than a medical condition. And when we incarcerate addicted individuals, we decrease their access to treatment and exacerbate the personal and societal consequences of their substance use. What’s more, drug laws are disproportionately leveraged against Black people and Black communities, driving societal and health disparities. The aura of illegality affects the treatment of people with addiction. For example, some treatment programs expel patients for positive urine samples, as if relapse were not simply a known symptom of the disorder and a clinical signal to adjust the treatment approach but instead actual wrongdoing.
Help and Healing
Stigma’s damaging effects go well beyond impeding care and care-seeking. Painful social and emotional effects like rejection, isolation, and shame—internalized stigma—drive drug-taking to alleviate one’s suffering, leading to a vicious cycle. It was internalized stigma that led my grandfather to end his life. Research supports the lesson I learned firsthand in my own family—that stigma is not alleviated solely by educating people on the science of a disease. Partly, it requires facilitating contact between a stigmatized group and the wider community. If people with substance use disorders can share their experiences, then empathy and compassion can begin to replace judgment and fear. For that to happen, addressing stigma must be a central prong of our public health efforts. If we’re going to end the current addiction and overdose crisis, we must treat combating stigma as no less important than developing and implementing new prevention and treatment tools.
We need a large-scale social intervention to change public attitudes toward addiction and people who have the disease. Besides ensuring proper training and the resources needed to help patients with substance use disorders, we need to seriously reconsider policies — not only laws but regulations and practices in health care and other settings — that promote viewing substance use as wrongdoing. And we must make it safe for patients and families to discuss addiction and remove the shame that interferes with its treatment.
WE LEARNED IN THE previous installments of this series that psychology is a discipline with a rich history. Plato and Aristotle, for example, created elaborate theories that attempted to account for a myriad of developmental issues: memory, perception, learning. Initial philosophers and theorists took an eclectic approach, exploring matters such as determinism, responsibility, mind versus body, empiricism, harmony, rationalism, and self identity. This tended to pull early theorists in many directions. When psychology emerged as a separate discipline, the initial impact tore in two the early influences of philosophy and religion. Today, psychology consists of a number of disciplines and concentrations. For the Christian, psychology must be infused with theological beliefs about our place in God’s world. Many evangelicals and other denominational Christians see no place for psychology or secular counseling in the church. In this installment, I will discuss free will and the personality. In the final installment, I will present the concept of “religious” or “Christian” counseling.
Free will has been considered countless times by theologians such as Augustine, Martin Luther, Alvin Plantinga, C.S. Lewis, and Wayne Grudem. Admittedly, it is the concept of free will that muddies the water most when discussing religious faith and psychology. Christianity teaches that man has the freedom to choose or reject God. Everyone is free to choose A or not-A. This designation is different than choosing A or B. If you’re offered a choice of A or B, then you are being given a choice between, Do you want an apple or an orange with your lunch? In this scenario you cannot choose something other than an apple or an orange. You are not free to pick anything you want, but rather to make your selection from the choices offered. If you’re just offered A, then it’s still a choice. In the example of A or not-A you must choose God or not God.
Augustine’s definition of free will is built on Plato’s “seeking of the good principle.” Augustine addresses man’s choice between good and evil (right and wrong). He said we are also free to accept or reject the love and grace of God. Luther said, “God… foresees, purposes and does all things according to His immutable, eternal and infallible will” (1). When asked why we perform evil deeds, Luther replied, “The human will is like a beast of burden. If God rides it, it wills and goes whence God wills. If Satan rides it, it wills and goes where Satan wills” (2). This is not the same as believing a benevolent God rides us to do good, while an evil devil rides us to do evil. We choose whom to allow in the saddle, so to speak. Plantinga writes, “…belief in God is not the same thing as belief that God exists, or that there is such a thing as “god” (3).
The drive of philosophy to get the “big picture” has heavily influenced the understandings of Christian theology. Consider the problem of evil in a world created by a loving and caring God. Atheists and skeptics claim this dichotomy either proves God does not exist, or He does exist and is unable or unwilling to abolish evil. Plantinga puts the argument of skeptics this way: “If God is benevolent as Christian theists claim, He must be just as appalled as we are at all this evil [in the world]. But if He is also as powerful as they claim, then presumably He is in a position to do something about it. So why does He permit it?” (4). Plantinga cites the free will defense, which claims we are free with respect to an action. He explains, “If a person is free with respect to a given action, then he is free to perform that action and free to refrain from performing it” (5).
A world containing individuals who are capable of both good and evil simply indicates such individuals are free to choose how they will behave. God created man with free will; He cannot cause them to do only what is right. Plantinga reminds us that what God created “went wrong” when our First Parents exercised their free will to disobey God. It might sound as though this contradicts man’s freedom to choose, but it does not. We are free to obey or disobey, but we are not free to choose the consequences of our decision. Frankly, free will must involve moral agency.
Theories of Personality
Questions regarding mind versus body, nativism versus empiricism, nature versus nurture, and genetic components of behavior have been examined over the decades in hope of understanding the human personality. The goal has been to arrive at a unifying theory of human nature. For example, are we inherently aggressive? Freud said yes; humanists like Carl Rogers and Abraham Maslow said no. Sigmund Freud believed aggression and emotional traps are rooted in a person’s early childhood experience—especially the dynamics of one’s relationship with a parent or primary care giver. B.F. Skinner described a form of learning in which a voluntary response is strengthened or weakened depending on its association with either positive or negative consequences. The strengthening of a response occurs through reinforcement. Skinner called this theory “operant conditioning.”
Maslow created a visual, which he termed the “hierarchy of needs.” This pyramid depicts various levels of physical and psychological needs that a person progresses through during their lifetime (6). Frustration at any level of “actualization” makes it nearly impossible to move to the next level. For example, if a child’s physiological needs are not met, developing a sense of safety and security is difficult to achieve. Albert Bandura’s Social Learning Theory states that virtually all forms of behavior can be learned (good traits and bad) simply through observational learning. Although he did not believe man precisely mimics those whom he or she observes, he believed man makes a deliberate, conscious decision to behave in the same way. This is crucial for understanding why violent men often come from a violent home (7).
Personality is one of man’s most important assets. It shapes our experiences from birth and will do so as we get older. It impacts our accomplishments, expectations, health, options, and behavior. For example, someone with a terrific personality is affable, pleasant, nice to be around, easy to get along with. Someone with a terrible personality may be aloof, hostile, aggressive, unfriendly, dominating, difficult to get along with. Many forces and factors shape personality during childhood and young adulthood. After that, our personalities stay pretty much the same throughout our lives. A new study shows a correlation between personality traits observed in children (as young as first graders) and adult behavior. Does the child share? Is he or she aggressive or demure; sociable or shy? Christopher Nave says, “We remain recognizably the same person” (8).
I believe it is unwise to resign people to “fate,” especially through such a glib and simplified approach as above. Personality is complex and changeable in different situations and with different people. I find myself vacillating at times depending on the social setting. I might drop an f-bomb in certain circles, but it is not likely I will do so while in church or while interacting with fellow believers or church leaders. I was often told during active addiction that I was a “Jekyll and Hyde.” Take a moment to consider how we hold many traits. Try writing down as many adjectives as you can think to describe what you are really like. If you do not hold yourself in high regard, whatever the reason, your list may present a dark and unhappy personality. The opposite will be true if you think well of yourself. Our personality is a collage of feelings we’ve adapted over the years in response to our environment—forces and factors that shape who we are. Personality refers to enduring characteristics, but these may change over time in response to new and forceful stimuli and circumstances.
Religion teaches that individuals are responsible for their actions, and identifies bad behavior as transgression. Schnikter and Emmons believe religion is overlooked and marginalized in personality psychology, despite the fact that religion was of great interest to the founding theorists of the field. Schnikter, et al. write, “Because of the recent surge in empirical research on religion from a personological perspective this claim is no longer convincing. One of the hallmarks of personality psychology that distinguishes it from other fields is its focus on a comprehensive understanding of the person. Accordingly, personality psychology should have a distinctive relationship with the psychology of religion” (9). Because religion and spirituality are concerned with our transcendent self, Schnikter and Emmons believe personality psychology is a worthy study subject.
René Descartes viewed human personality as the product of an interaction between divine and primal forces. Jean-Paul Sartre theorized that personality traits are developed through the projects we choose in life, and because we can choose what we devote our lives to we can change our character traits. Webber writes, “An individual’s character is that person’s collection of character traits, and these can be defined as relatively stable dispositions to think, feel, and behave in certain ways in certain situations. Two traditional examples are bravery and cowardice, the dispositions to think, feel, and behave in a brave or cowardly manner in the face of real or apparent danger” (10). Consider, then, the generous man or woman. He or she frequently offers aid to neighbors, has several favorite non-profit organizations or charities, and tithes unselfishly at church. And there’s the alcoholic or drug addict who comes to know Jesus and experiences a radical change in character. He stops abusing alcohol or drugs and joins a church. Through his transformation, he begins to give generously to the church and volunteers his time for groups and programs. He passes the message of transformation along to newcomers.
When a person visits a psychologist or a psychiatrist, that person’s problems or concerns are being understood and addressed through the lens of the practitioner, also known as his or her theory of personality. Most psychological theories deny spirituality or downplay it at best. Secular counseling typically denies the spiritual dimension of humanity. Many of today’s personality theories have roots in the Enlightenment philosophy begun by Descartes. While these theories give us helpful insight and understanding, their philosophical foundations tend to be rationalistic, materialistic, and evolutionary in nature. Enlightenment theory lends itself to doubt and skepticism, limiting what they assign to a belief in God, a created world, and the concept of right versus wrong.
From a Christian perspective, Ladd (11) outlines three ways in which scholars have interpreted what can be called the anthropology of Paul:
Scholars of an older generation understood 1 Thessalonians 5:23—where Paul prays for the preservation of the spirit, soul, and body—to be a psychological statement and understood Paul in terms of trichotomy… spirit, soul, and body are three separable parts of man. Other scholars have seen a dichotomy of soul and body. Recent scholarship has recognized that such terms as body, soul, and spirit are not different, separable faculties of man but different ways of viewing the whole man.
Generally, psychology says man cannot change his personality. Christianity agrees in part. When an individual accepts the redemptive work of Jesus Christ on the cross, and identifies with His death, burial, and resurrection, his or her character begins to change. Paul said, “Therefore, if anyone is in Christ, he is a new creation. The old has passed away; behold, the new has come” (2 Cor. 5:17). Paul further tells us to put off our old self, which belongs to our former manner of life, and to be renewed in the spirit of your minds, putting on the new self (see Eph. 4:22-24). Henry speaks of this transformation: “By the new man, is meant the new nature, the new creature, directed by a new principle, even regenerating grace, enabling a man to lead a new life of righteousness and holiness” (12) (italics added). This is what Paul meant by “all things.”
Isaiah said we must forget “the former things” and instead “do a new thing” (see Isa. 43:18-19). We should walk in a manner worthy of our calling in Christ (see Eph. 4:1). Yet, we are not left to our own (human) devices. Paul provides us with the necessary spiritual guidance. In the Book of Romans, he presents perhaps the closest thing in the New Testament to systematic theology. Chapters 6, 7, and 8 present the core of Christian doctrine, and as such is one of my favorite sections of Scripture. Paul changes the focus of his teaching in Romans 12 from theological to practical. Now, we are instructed to present our bodies as a “living sacrifice,” which is considered reasonable (do this at the very least) given the cost of our redemption. Practically speaking, our service requires a reorientation of our thinking: “Do not be conformed to this world, but be transformed by the renewal of your mind, that by testing you may discern what is the will of God, what is good and acceptable and perfect” (see Rom. 12:2). Henry writes, “Conversion and sanctification are the renewing of the mind; a change, not of the substance, but of the qualities of the soul” (13).
For millennia religion and psychology stood in staunch opposition. The early theorists of psychology, however, were theists and philosophers. They remarkably shared a similar quest to understand the whole man: body, mind, spirit. It is not surprising that this centuries-old search passed through stages such as determinism, empiricism, rationalism, good versus evil, and self identity. In order to grasp the existence and attributes of God, we must move from knowing about God to knowing God. This is how we come to grips with who we are in Him, and who we are without Him. In so doing, we are in a better position to accept His forgiveness, grace, mercy, and salvation. It is through accepting that we become “a new creature.” However, we do not loose our personality; nor are we magically rendered immune to “being human.” Instead, transformation begins in the heart (spiritual) and proceeds through the mind (renewal of thoughts). The “old us” that dies with Christ is our unregenerate sinful self. The “new us” is our regenerate self that rises with Him in righteousness. Through spiritual growth, we move from “spiritual” to “practical” change—newness of character. Transformation, regardless of its impetus, necessarily requires a belief (faith) in the potential for change, and must be followed by action steps (practical) that allow us to begin “walking the new walk.”
(1) Hergenhahn and Henley, An Introduction to the History of Psychology, 7th ed. (Belmont, CA: Wadsworth Cengage Publishing, 2014), 97. (2) E.F. Winter, Erasmus & Luther: Discourse on Free Will (New York, NY: Continuum, 2005), 97. (3) Alvin Plantinga, God, Freedom, and Evil (Grand Rapids, MI: Eerdmans Publishing Co., 1974), 1. (4) Ibid., 9. (5) Ibid., 29. (6) Duane P. Schultz and Sydney Ellen Schultz, Theories of Personality, 11th ed. (Boston, MA: Centage, 2017), 250-251. (7) Schultz, Ibid., 343-350. (8) ChristopherNave, “Personality Set For Life by First Grade,” Live Science (Aug. 6, 2010). URL: https://www.livescience.com/8432-personality-set-life-1st-grade-study-suggests.html (9) Sarah H. Schnikter and Robert A. Emmons, “Personality and Religion” in Handbook of Personality: Theory and Research, O. P. John & R. W. Robins, ed. (New York, NY: Guilford Press, 2021), 707–723. (10) Jonathan Webber, “Sartre’s Theory of Character,” European Journal of Philosophy (2006), 94-116. (11) George Eldon Ladd, A Theology of the New Testament (Grand Rapids, MI: William B. Eerdmans Publishing Co.), 1974. (12) Matthew Henry, Matthew Henry’s Concise Commentary on the Whole Bible (Nashville, TN: Thomas Nelson, Inc., 1997), 1150. (13) Henry, Ibid., 1087.
Dr. Nora Volkow, Executive Director National Institute on Drug Abuse
The provisional drug overdose death statistics for 2020 confirmed the addiction field’s worst fears. More people died of overdoses in the United States last year than in any other one-year period in our history. More than 93,000 people died. The increase from the previous year was also more than we’ve ever seen—up 30 percent. These data are telling us that something is wrong. In fact, they are shouting for change.
The provisional drug overdose death statistics for 2020 confirmed the addiction field’s worst fears. More people died of overdoses in the United States last year than in any other one-year period in our history. More than 93,000 people died. The increase from the previous year was also more than we’ve ever seen—up 30 percent. These data are telling us that something is wrong. In fact, they are shouting for change.
It is no longer a question of “doing more” to combat our nation’s drug problems. What we as a society are doing—putting people with drug addiction behind bars, under-investing in prevention and compassionate medical care—is not working. Even as we work to create better scientific solutions to this crisis, it is beyond frustrating—it is tragic—to see the effective prevention and treatment tools we already have just not being used. The benefits of providing effective substance use disorder treatments—especially medication for opioid use disorder—are well-known. Yet decades of prejudice against treating substance use disorders with medication has greatly limited their reach, partly accounting for why only18%of people with opioid use disorder receive medications. Historical reluctance to provide these treatments and of insurers to cover them reflects the stigma that has long made people with addiction a low priority.
We must eliminate the attitudes and infrastructure barring treating people with substance use disorders. This means making it easier for clinicians to provide life-saving medications, expanding models of care like digital health technologies and mobile clinics that can reach people where they are, and ensuring that payers cover treatments that work. The science of the matter is unequivocal: Addiction is a chronic and treatable medical condition, not a weakness of will or character or a form of social deviance. But stigma and longstanding prejudices—even within healthcare—lead decision-makers across healthcare, criminal justice, and other systems to punish people who use drugs rather than treat them. That approach may be simpler than asking us as a society to have compassion or care for people with a devastating, debilitating, often fatal disorder. Butthe risk of incarceration does not deter drug use, let alone address addiction; it perpetuates stigma, anddisproportionately harms the most vulnerable communities.
Evidence-based harm reduction, such as syringe services programs, also need to be a part of any solution to our drug crisis, as these have been shown to reduce HIV and hepatitis C transmission, and help link people to treatment for addiction and other conditions. While the federal government has embraced evidence-based harm-reduction programs, many communities continue to resist them, erroneously thinking they sanction or encourage drug use. Multiple independent studies have shown that they don’t. Researchers are also evaluating innovative but historically controversial strategies operating abroad like overdose prevention centers, where people can use substances under medical supervision and access other health services, to evaluate cost-effectiveness and ability to reduce deaths and improve health.
Part of the failure of the current approach to the drug crisis arises from the unrealistic expectation that people should—and can—just stop using drugs. Little concern is shown for people with addiction unless and until they are drug-free, but the reality is that difficulties and resumed use typically mark the recovery journey. Compassion, care, and support need to extend to those still using drugs and those who return to drug use, not just to those who can satisfy the stringent standards of abstinence. Everyone with a substance use disorder, regardless of whether they are currently using drugs, needs good healthcare and may also need help with housing, employment, and childcare needs.
To prevent young people from misusing drugs and to keep people from all ages from developing substance use disorders, our nation must address the social and economic stressors that increase the risk of drug use, such as poverty and housing instability, unsafe neighborhoods and schools, and other effects of a changing economy including social isolation and despair. Drug overdose deaths are one component of the “deaths of despair” that, along with suicide and alcohol-related illness, havecaused life expectancy to declinein the U.S., even before the1.5-year drop in 2020 caused largely by the COVID-19 pandemic. On the ground, evidence-based interventions can make a big difference: Universal prevention programs as well as interventions targeted to the most at-risk families and youth not only reduce the risk of later drug taking and addiction but have radiating benefits on other aspects of mental and physical health.
This poses a question of collective willingness to invest in these measures. The long-term savings in healthcare and justice costs relative to the costs of prevention interventions can be substantial. But they are long-term investments with benefits that will take time to accrue, and the nature of our society is to look at short-term bottom lines and expect immediate results. Radical change to save lives is long overdue. It is crucial that scientists help policymakers and other leaders rethink how we collectively address drugs and drug use, looking to the evidence base of what improves health and reduces harms across communities, and funding research to develop new prevention and treatment tools.
From the Blog of Dr. Nora Volkow Executive Director NATIONAL INSTITUTE ON DRUG ABUSE
August 9, 2021
Our understanding of substance use disorders aschronic but treatable health conditionshas come a long way since the dark days when they were thought of as character flaws — or worse. Yet our societal norms surrounding drug use and addiction continue to be informed by unfounded myths and misconceptions. Among the most harmful of these is the scientifically unfounded belief that compulsive drug-taking by individuals with addiction reflects ongoing deliberate antisocial or deviant choices. This belief contributes to the continued criminalization of drug use and addiction.
While attitudes around drug use, particularly use of substances like cannabis, have significantly changed in recent decades, the use and possession of most drugs continue to be penalized. Punitive policies around drugs mark people who use them as criminals, and so contribute to the overwhelming stigma against people contending with an often-debilitating and sometimes fatal disorder — and even against the medical treatments that can effectively address it.Stigma has major negative impacts on health and well-being, which helps explain why only 18% of people with drug use disorders receive treatment for their addiction. Stigma impedes access to care and reduces the quality of care individuals receive. People with addiction, especially those who inject drugs, are often distrusted when presenting for care in emergency departments or when visiting other providers. They are often treatedin a demeaning and dehumanizing way. And physicians holding stigmatizing attitudes may not provide adequate evidence-based care for patients with addiction.
A recent national surveyof primary care physicians found that although most believe that opioid use disorder is a treatable medical condition, most also expressed similar stigmatizing views toward people with opioid use disorder that are held by the wider population. More stigmatizing attitudes among primary care physicians were correlated with lower use of medication in treatment of opioid use disorder and lower support for policies designed to increase access to those medications. The perception of stigma by people with substance use disorders may cause them to avoid or delay engaging with health care or to conceal their drug use when interacting with health care professionals. Even when care is confidential, residential treatment or daily visits to receive treatment, particularly in close-knit communities, can be noticed and trigger judgment. According to the National Survey of Drug Use and Health, fear of negative opinions by neighbors or people in their community is one of the reasons people who know they need treatment for a substance use disorder avoid seeking it.
Fear of possible criminal consequences for drug use can shape people’s health decision-making in many potentially deleterious ways. Substance use may be an important fact to consider in a routine medical visit, so its concealment can lead a physician to overlook major factors in a patient’s health. In some states, pregnant people with substance use disorders risk being charged with child abuse or otherwise losing their parental rights if their child shows evidence of prenatal drug exposure or is born with neonatal abstinence syndrome. Fear of such consequences of substance use may cause individuals to avoid much-needed prenatal care, treatment, and other services.
The stigma against addiction extends to those who provide care for the condition and to the medications and harm-reduction measures that are used to address it. For example, methadone and buprenorphine arehighly effectiveat helping people recover from opioid use disorders, but lingering prejudice that conflates taking medication with the use of harmful substances is one factor that prevents people from being treated with these medications. Although treatment for addiction is becoming more integrated into medicine, it has faced major challenges on many fronts and requires overcoming health care providers’ attitudinal barriers as well as hurdles arising in part from confidentiality protection laws that may limitgathering and sharing dataon patients’ use of illicit substances. When doctors don’t ask about patients’ drug use, they may miss information that is important to their care. Stigma also contributes to insurers setting restrictive limits on what they will cover for medications to treat substance use disorders.
Many people intersect with the criminal justice system as a direct or indirect result of their substance use disorders, and the experience may worsen their addiction and their physical and mental health. Although roughly half of people in prison have a substance use disorder, few receive treatment for it. People with untreated opioid use disorder arehighly likely to return to drug useupon release, all too often with fatal consequences because of lost tolerance to the drug while in prison. Imprisonment itself not only increases the likelihood of dying prematurely, but also negatively impacts mental health and social adjustment via the stigma of having been incarcerated. And it has radiating effects: Incarceration of a parent increases their children’s risk of drug use, for example.
Research has consistently shown that when people interact with members of a stigmatized group and hear their stories directly it has a powerful de-stigmatizing effect more than simply educating the public about the science underlying a condition. But while a growing number of people in recovery are speaking openly about their past use and their current struggles to keep sober, people who use drugs actively — either because of an untreated addiction or during a period of relapse or even simply as a matter of personal choice outside the context of a use disorder — are not free to do so without fear of legal consequences. The silence of people living with active drug use disorders due to the stigma associated with their condition means the wider public has no opportunity to hear from them and no opportunity to revise their prejudices, such as the belief that addiction is a moral failing or a form of deviance.
An effective public health response to substance use and substance use disorders must consider the policy landscape of criminalizing substance use, which constitutes a major socially sanctioned form of stigma. In addition to research already underway on stigma and stigma reduction at the National Institutes of Health, research on the positive and possible negative outcomes associated with alternative policy models that move to prioritize treatment over punishment are also urgently needed, as such models could remove a major linchpin of the stigma around drug use and addiction and improve the health of millions of Americans.
ALCOHOL. POWER. MONEY. FOOD. SEX. All of these are capable normal appetites which can morph into full-blown addictions. From a personal perspective, my desires were out of hand, and were causing ruin in my life. As hard as I struggled, getting my problem appetites under control had proved out of the question. Desire had literally taken over my body. Depression and anxiety grew to be increasingly debilitating. Euphoria was unreachable, so I began to find my “warm and fuzzy” through booze, opiates, cannabis, and cocaine. I was chasing a “feel good” release through chemicals, yet the chase proved to be extremely unfulfilling. Appetites once held in healthy balance were now compulsions. I was living in Hotel California—I could check out any time I’d want, but I could never leave. My original God-given appetites were now painful addictions.
Although the apostle Paul was likely not an “addict,” he said, “I do not understand my own actions. For I do not do what I want, but I do the very thing I hate” (Rom. 7:15, ESV). He added, “For I do not do the good I want, but the evil I do not want is what I keep on doing” (7:19). This passage became my mantra; unfortunately, it also became a huge loophole. I would often say to myself, “How can I expect to win out over my ruined appetites if Paul couldn’t?” Paul, an apostle, a converted Jew, who received direct discipling from Jesus Christ (see Gal. 1:11-24) was unable to control his appetite for sin; or so I thought. And voila, instant loophole!(See my blog article“Do You Look for Loopholes as a Christian?”).
Gluttony is “habitual greed or excess in eating or consuming.” From the Latin, gula, “to gulp down or swallow,” gluttony is over-indulgence. In this instance, greed involves an intense or selfish desire for something, especially wealth, power, or food. The most common type of gluttony, uncontrolled eating, leads to obesity and a litany of related health risks. Because gluttony is closely related to drunkenness, drug abuse, greed for money, or a desire for excessive power, it is considered a sin in Christian theology. Gluttony involves living for self, putting all others second. It can be said that gluttony shows contempt for society and for one’s own body. Paul said, “Do you not know that your body is a temple of the Holy Spirit within you, whom you have from God? You are not your own, for you were bought with a price. So glorify God in your body” ( 1 Cor. 6:19-20, ESV).
Unfortunately, gluttony seems to be a bad habit Christians like to ignore. Some teachings say the word “gluttony” cannot be found in Scripture. Yet, we read “…and they shall say to the elders of his city, ‘This our son is stubborn and rebellious; he will not obey our voice; he is a glutton and a drunkard'” (Deut. 21:20). John states in his first epistle, “Do not love the world or the things in the world. If anyone loves the world, the love of the Father is not in him. For all that is in the world—the desires of the flesh and the desires of the eyes and pride of life—is not from the Father but is from the world” (1 John 2:15-16) [italics added]. Paul said in Philippians, “Their end is destruction, their god is their belly, and they glory in their shame, with minds set on earthly things” (Phil 3:19) [italics added]. Proverbs 28:7 says a glutton “shames his father.” Paul writes, “One [of them], a prophet of their own, said, ‘Cretans are always liars, evil beasts, lazy gluttons'” (Tit. 1:12) [italics added]. Ben Giselbach of PlainSimpleFaith.com writes, “…’gluttony’ does not appear in any of the Bible’s big this-will-keep-you-out-of-heaven lists… New Testament writers are particularly nonchalant about one’s diet and portion control. Food neither commends nor condemns us before God” (1).
It is likely Giselbach is referring to the “legalistic” approach of dietary matters, indicating New Covenant Christians are not bound by dietary laws. However, gluttony, as addressed by Scripture, is not a dietary concern; rather, it is an orientation of the heart toward an excess appetite for the desires of the flesh (1 John 2:16). Let us examine Paul’s language in Romans 7 and see how it relates to a lack of control over one’s sin nature. He first establishes a truth for all believers: “For we know that the law is spiritual, but I am of the flesh, sold under sin” (7:14). This is the springboard for Paul’s rant: “For I do not understand my own actions. For I do not do what I want, but I do the very thing I hate. Now if I do what I do not want, I agree with the law, that it is good. So now it is no longer I who do it, but sin that dwells within me… For I do not do the good I want, but the evil I do not want is what I keep on doing. Now if I do what I do not want, it is no longer I who do it, but sin that dwells within me” (7:15-17, 19-20).
The following is from Peterson’s translation The Message:
I can anticipate the response that is coming: ‘I know that all God’s commands are spiritual, but I’m not. Isn’t this your experience?’ Yes. I’m full of myself—after all, I’ve spent a long time in sin’s prison. What I don’t understand about myself is that I decide one way, but then I act another, doing things I absolutely despise… I decide to do good, but I don’t really do it; I decide not to do bad, but then I do it anyway. My decisions, such as they are, don’t result in actions. Something has gone wrong deep within me and gets the better of me every time. It happens so regularly that it’s predictable. The moment I decide to do good, sin is there to trip me up. I truly delight in God’s commands, but it’s pretty obvious that not all of me joins in that delight. Parts of me covertly rebel, and just when I least expect it, they take charge (2).
I cannot share accurately enough how convicted I felt as I typed the above quote, realizing my tendency in the past to look for excuses for my behavior rather than changing it. Some biblical scholars believe Paul is speaking about the sin dilemma in man rather than a personal struggle within himself. However, studies during my master’s in theology and collateral readings have convinced me otherwise. Paul, as depicted in the motion picture Paul, Apostle of Christ, directed by Andrew Hyatt, became very humble following his conversion to Christianity. He counted his rabbinical education as nothing; rather, he wanted now to know nothing but Christ and Him crucified (1 Cor. 2:2). His ministry to the non-Jews of the world was critical, and his lessons on God’s grace in face of our sometimes deliberate sinful rebellion (clearly presented in Romans 7) was necessary for his ministry to the Gentiles.
After becoming a Christian, Paul was painfully reminded often of his past persecution of Christians, even having some of them executed. Now, he was a member of the Body of Christ, and an heir to the promise God made to Abraham. Paul taught often on the true purpose of Mosaic Law and subsequent rabbinical laws—to reveal the sinful nature of man and his inability to obey God under his own power. Although the Law was good and holy (Rom. 7:12), it did not provide salvation for the nation of Israel. Paul wrote, “For by works of the law no human being will be justified in his sight, since through the law comes knowledge of sin. But now the righteousness of God has been manifested apart from the law, although the law and the Prophets bear witness to it—the righteousness of God through faith in Jesus Christ for all who believe. For there is no distinction: for all have sinned and fall short of the glory of God, and are justified by his grace as a gift, through the redemption that is in Christ Jesus” (Rom. 3:20-24). Paul’s central argument in his letter to the Romans is the eternal plan of God for the salvation of sinners.
What purpose, then, is the Law?The extent of sin would never be fully known apart from the Law. We would not know sin except through the Law (see Rom. 7:7).
We read in the Recovery Devotional Bible, “[It is a myth that] Christians have victory over sin, [making sin] a problem only for those with weak faith. All Christians struggle with sin… we see believers throughout the Bible struggling with sin. We find special comfort that the apostle Paul described his struggle as a war (Rom. 7:23) [italics added] and agonized over it” (3). Paul was not, however, avoiding responsibility. He was not saying, “Hey, I didn’t do it—sin did.” Paul realized we only find freedom from our sinful nature when we accept the fact that we will never be completely free. The urge to sin will live in our flesh until we come into the fullness of our redemption and receive a new glorified body. These urges are sometimes stronger, sometimes weaker. As a minister of the New Covenant, Paul never once indicates that his status as a Pharisee among Pharisees provided any assurance of his salvation or his standing before the Father.
The Choice Factor
Choice is an interesting word. It implies free will. Augustine of Hippo rightly believed evil cannot exist within God, nor be created by God; rather, it is a by-product of man’s ability to choose his behavior. Augustine maintained that it is vital for us to have free will because we cannot live well without it. Admittedly, no greater question has been raised (both for and against the existence of God) than the freedom to do evil. Why would God permit evil to exist? According to Augustine, human nature was originally created blameless and without any fault [Latin, vitium]. As a result of sin, everyone born of Adam “requires a physician, because [he] is not healthy.” Augustine clearly states that the weakness which darkens and disables the good things did not come from the blameless maker but from original sin, which was committed by free will. He said, “For this reason, our guilty nature is liable to a just penalty” (4).
According to Gonzalez, Augustine concluded that evil, though real, was not a thing, but rather an orientation away from that which is good and toward that which is not good. This seems to help Augustine understand that God did not create evil. He believed only that which man decides of his own will (rather than that which is dictated by circumstances or directed by a separate entity) is properly called “free.” It is the will that is created by God, not evilness itself. This is no mere matter of semantics. Free will allows man to make his own decisions. As Gonzalez notes, “The origin of evil, then, is to be found in the bad decisions made by both human and angelic wills—those of the demons, who are fallen angels” (5). Augustine’s position is akin to theological determinism, but not in the manner we might expect. He argued that man prefers the joy of “doing good.” Origen of Alexandria thought that affirmation of free will distinguishes Christianity from deterministic accounts of the human condition and constitutes the basis for man’s moral responsibility. Suffering comes from human choice, not from a cosmic clash between good and evil. In this manner, free will is a rational capacity to choose between what is good and what is not good. Admittedly, freedom is likely an attribute of the agent rather than of the will itself.
Regarding our God-given appetites, the danger is not in seeking to fulfill them; it is when we choose to fulfill them with something that does not belong there. Attempting to fill one thing with something that does not fit causes our appetites to begin the cycle of becoming unhealthy or dangerous. To satisfy an appetite completely, we need to choose the actual thing that is being desired. A great example is the choice to view pornographic images for satisfaction of one’s sexual urges outside of an established reciprocal relationship with someone. Pornography provides an inroad for something utterly destructive. Under control, appetites help us to exist; an out-of-control appetite destroys everything in its path like a runaway brush fire. Consequently, there is a battle between flesh and spirit; man and God; self and others. The flesh wants to feel good no matter the cost. Frankly, we want pleasure and we want it now.
Our enjoyment of food, music, sex, drugs, alcohol, affection, all stimulate a common pathway in the brain that leads directly to our “pleasure center.” This reward center, physically located in the lateral hypothalamus, causes us to feel pleasure when stimulated. This is a good thing; life without pleasure or reward would be rather daunting. Yet, when pleasure becomes the thing we are searching for, we soon find ourselves crying, more, more, more! We learn that there is never enough to satisfy. Sin is the result of an appetite going astray and being filled by something other than what God intended it to be filled with. There is a hint of idolatry in this concept. For me, poor choice was rooted in self-indulgence and obsession with self-entitlement. I indulged in pleasure to avoid pain. I was concerned only with reducing my physical, emotional, or psychic pain, and did not care about the consequences of my choices. Self-indulgence is the excessive satisfaction of our sensual appetites and desires for the specific purpose of pleasing the self.
In the second of this two-part lesson we will examine change: how it begins; how to take responsibility; how to stop blaming everyone else. Change cannot happen until we stop making excuses. We need to stop believing our own lies! We will look at “purpose” over mere “existence,” which will aid in our developing and nurturing healthy relationships. We will learn how to cultivate “divine” desires, let go of guilt, and live a surrendered life.It is through this surrendered life that we become the arms and hands and legs and eyes and ears and mouth of Jesus. We yield our will in service to our neighbors. It is not possible to be like Christ while maintaining an I am first position. God is the key to any success we may have in learning to control our appetites. Jesus Christ must be the force behind all we do; the one directing and controlling where we are headed; the foundation upon which we build our life.
(1) Ben Giselbach, “The Evil of Gluttony, and Why You Might Not be Guilty of It,” PlainSimpleTruth.com (July 13,2015). URL: https://plainsimplefaith.com/gluttony/ (2) Eugene Peterson, The Message//Remix: The Bible in Contemporary Language (Colorado Springs, CO: NavPress: 2006), 1653. (3)Recovery Devotional Bible: NIV Edition, Verne Becker, general editor (Grand Rapids, MI: Zondervan, 1973, 1978, 1984), 1241. (4) Augustine of Hippo, “On Fallen Human Nature,” in The Christian Theology Reader (Chichester, West Sussex, UK: Wiley Blackwell, 2017), 349. (5) Justo L.Gonzalez, The Story of Christianity, Vol. I: The Early Church to the Dawn of the Reformation (New York, NY: Harper One, 2010, 247.
Written by Steven Barto, B.S., Psy., M.A. Theology
FOR THE FOURTH TIME this newscast I grabbed for the remote and muted yet another 90-second commercial touting the glorious new activity of gambling online. Sexy young voluptuous blondes and brunettes with plunging necklines smile seductively and splay decks of cards, gesturing. These TV ads bear the names of so-called “trustworthy” gambling institutions, and promise a risk-free day of odds-laying up to $500, failing to remind that the house always wins in the end or such games of chance would shrivel up and blow away. One TV spot says “…now you can have the name of MGM Grand Casino in your pocket.” Never has a more ironic statement been made!
Steve Rose, PhD, a certified gambling counselor and problem-gambling prevention specialist, writes, “Since the pandemic began, there has been an explosion of online gambling.” With experts warning of this ticking time bomb, responsible gambling safeguards are sparse. Admittedly, online gambling is not new. However, the pandemic accelerated demand, leading to higher rates of riskier gambling. According to a report published by the Responsible Gambling Council (RGC) of Canada, one out of three online gamblers admit to being influenced by pandemic lockdowns (1).
Due to ease of access, online platforms make it easier to use gambling as a way to cope with underlying issues such as anxiety and depression. In fact, the RGC survey found that anxiety and depression are major factors contributing to high-risk gambling. Individuals with severe depression are almost five times more likely to engage in high-risk gambling. Typical depression symptoms such as low mood, apathy, and social isolation are a barrier to people traveling to live venues to gamble. With online gambling, anxious and depressed people can engage in round-the-clock gambling while distracting themselves from their circumstances from the ease of their living room.
A Prolific Online Presence
I did an Internet search with the words the perils of impulsive online gambling. The site listed at the top of my search results was an AD, which said Pennsylvania Online Casino – Real Cash Payouts in 24 Hours!The second result listed saidBest Online Casinos in PA 2021 – Get $1,500 Welcome Bonus! Internet gambling is reeling in college students and young children along with adults. The COVID-19 crisis, and the confinement and other restrictions associated with it, represent a unique situation that carries financial consequences for the population. People worrying about the future, possibly spending more time than usual online, are at risk for falling hard for distraction or “easy solutions” to their woes.
Sports gambling in particular has soared during the pandemic and continues to climb. CBS News reports that gamblers placed $4.3 billion in bets on Super Bowl LV, marking “the largest single-event legal handle in American sports betting history.” In sports betting, a “handle” refers to the total amount of money wagered by bettors. About 7.6 million people placed bets on the game through platforms like FanDuel and DraftKings, marking a 63% increase from bets place on the 2020 Super Bowl. Additionally, more than 47 million Americans placed bets on March Madness games (2). Casey Clark, a senior vice president at the gaming association, said “You weren’t going to in-person sporting events and you weren’t going to brick-and-mortar sportsbooks [where gamblers can wager on various competitions].” He said more than 100 million people live in a state where gambling is now legal. Not long ago, that was only in Nevada (3).
Salerno and Pallanti write, “The COVID-19 pandemic has exerted a dramatic impact on everyday life globally. In this context, it has been reported that the lockdown and social distancing may have exerted an impact even on gambling behavior, not only by increasing gambling behavior in those affected by this disorder but even contributing to the occurrence of new cases” (4). According to their peer-reviewed paper, studies performed in different countries around the world have reported psychological and mental health problems due to the changes caused by the pandemic, including stress, anxiety, and depressive symptoms. Moreover, the lockdown and social distancing exerted an impact on gambling behavior, not only by increasing gambling incidents in those affected, but even contributing to the occurrence of new cases of problematic gambling.
Hodgins and Stevens write, “…the impacts of the COVID-19 pandemic on gambling and problematic gambling are diverse – possibly causing a reduction in current or future problems in some, but also promoting increased problematic gambling in others” (5). The study says, “At the same time that land-based gambling accessibility decreased during the pandemic, online gambling sites continued to operate. Some media reports indicated that online gambling business flourished during this time, and that the pandemic served to promote this increasingly popular gambling format” (6). Online gambling sites typically include the full range of types of gambling, including lottery ticket sales, casino table games such a roulette, blackjack and craps, slot machines, online poker and sports betting.
Like a Drug
Gambling, a leisure pursuit for most individuals, has the potential to cause harm to the gambler, their family and the community (7, 8). It is considered to be a potentially addictive behavior, which for some individuals can lead to gambling disorder (GD). GD is found in the DSM-5 under Unspecified Other (or Unknown) Substance-Related Disorder. This category applies to presentations in which symptoms characteristic of an other (or unknown) substance-related disorder cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate, but do not meet the full criteria for, any specific substance-related disorder or any of the disorders in the substance-related disorders diagnostic class (9). It is critical to note that, according to clinical studies, gambling addiction activates the same brain pathways as drug and alcohol cravings. Online gambling is considered to be a particularly problematic gambling format given the relative lack of constraints on how and when it can be accessed, its solitary nature, and the wide variety of types of gambling available.
David Zendle says a variety of practices have recently emerged which relate to both video games and gambling. He writes, “These range from opening loot boxes, to e-sports betting, real-money video gaming, token wagering, and social casino spending” (10). A blurring of the lines has occurred between video games and gambling activities. The most widely-discussed example of this convergence are loot boxes: Items in video games that may be bought for real-world money, but which contain randomized contents. In other words, your expenditure may lead to a “goose egg,” but the risk becomes tantalizing. Loot boxes share several formal features with gambling, and there has been widespread interest in the idea that engaging with loot boxes may lead to problem gambling. The more frequently gamers use loot boxes, the more severe their gambling problems tend to be (11). Certainly, you can see how this phenomenon places chronic gamers (especially younger players) at great risk for developing a gambling addiction.
Gamblers Anonymous (GA) was founded in 1957. It is an international fellowship of people who have a compulsive gambling problem whose approach is based upon the 12-step method of recovery from addiction initially established by Alcoholics Anonymous. Related programs include Narcotics Anonymous, Cocaine Anonymous, and Over-eaters Anonymous. GA believes gambling disorder involves repeated problematic gambling behavior that causes significant problems or distress. It is also called gambling addiction or compulsive gambling. Though Gamblers Anonymous is not associated with any religious group or political affiliation, some people find the 12-step principle of surrendering your problems to a higher power to have distinctly religious overtones. However, Gamblers Anonymous is welcoming of people of all ages, religions, and racial backgrounds—you just need to want to end your gambling addiction.
Gamblers Anonymous is a community of people who want the same goal: freedom from gambling addiction. Many Gamblers Anonymous members may also be struggling with other mental health or behavioral addictions. As a group, Gamblers Anonymous members share their wisdom, experiences, ideas for maintaining recovery, and healthy habits so that others may benefit. Members offer each other support, understanding, compassion, and solace when times are tough. Often, Gamblers Anonymous members will serve as sponsors to newer members who need more intensive support or a person to call when urges hit.
Are You Addicted to Gambling?
According to the DSM-5, persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress is indicated by the individual exhibiting four (or more) of the following in a 12-month period (12):
Needs to gamble with increasing amounts of money in order to achieve the desired excitement.
Is restless or irritable when attempting to cut down or stop gambling.
Has made repeated unsuccessful efforts to control, cut back, or stop gambling.
Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble).
Often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed).
After losing money gambling, often returns another day to get even (“chasing” one’s losses).
Lies to conceal the extent of involvement with gambling.
Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling.
Relies on others to provide money to relieve desperate financial situations caused by gambling
Television advertisements for gambling sites is a huge issue with me. I am sensitive to addiction issues because of my 40-year-plus struggles with alcohol and drug addiction. Looking over the nine criteria listed above for gambling addiction, I can honestly say I exhibited much of the same obsessive behaviors as they pertained to drinking and getting high. Addiction messes with the brain chemistry of the addict by taking hostage the chemicals associated with pleasure. The “computer chips” of the brain are neurons: billions of cells that are organized into circuits and networks. Each neuron acts as a switch controlling the flow of information. If a neuron receives enough signals from other neurons that it is connected to, it fires, sending its own signal on to other neurons in the circuit. To send a message, a neuron releases a neurotransmitter into the gap (or synapse) between it and the next cell. The neurotransmitter crosses the synapse and attaches to receptors on the receiving neuron, like a key into a lock. This causes changes in the receiving cell. Other molecules called transporters recycle neurotransmitters (that is, bring them back into the neuron that released them), thereby limiting or shutting off the signal between neurons.
Drugs interfere with the way neurons send, receive, and process signals via neurotransmitters. Some drugs, such as marijuana, opioid pain medications, and heroin, can activate neurons because their chemical structure mimics that of natural neurotransmitters in the body. These chemicals are dopamine, oxytocin, serotonin, and endorphins (abbreviated DOSE). Because heroin and other substances are extremely potent compared to these naturally-occurring brain chemicals, the brain is incapable of producing them at a level that can reproduce the intensity, leading the addict to develop a craving for his or her drug of choice.
Gambling addiction works by hijacking the brain’s neurochemicals and learned behaviors that activate the brain’s reward center. Remarkably, gambling behavior in such individuals has the same capacity to stimulate the brain as does dopamine, oxytocin, serotonin, and endorphins. In addition, the gambling addict feels rewarded by the intermittent thrill of winning. When the need to win outweighs the risk of losing, the gambling addict begins to exhibit many of the criteria noted in the DSM-5 listed above. At this point, gambling is no longer a form of entertainment. Gambling, as with drug or alcohol addiction, becomes both the problem and the solution. In other words, the addict is now locked into a pattern of behavior where he or she continuously expects to replicate the early “high” of gambling or abusing addictive substances. The brain is hijacked by the randomness of reward.
Addiction can rewire the chemical circuitry of the brain to the point that it seems impossible to quit the addictive behavior. Even though gambling does not involve ingesting chemical substances, it produces the same response as any drug. Gambling addiction is not about money or greed. As the harms outweigh the entertainment value, the gambler looses control and becomes fixated on winning back losses. Because compulsive gambling is a progressive illness, the will to gamble becomes irresistible. Adolescents and teens are at risk for developing a gambling addiction at a time when social and emotional growth is most vulnerable to change. Adolescence is characterized by increased risk-taking, novelty seeking, and locomotor activity, all of which suggest a heightened appetitive drive.
Although teens can gamble casually, the pressure to “fit it” or establish “street cred,” and times of stress or depression, can trigger overwhelming urges to gamble. Widespread neurobiological changes such as shifts in brain matter composition can complicate addiction in teens. Finally, adolescents appear especially sensitive to rewarding cues, as evidenced by exaggerated neural responses when exposed to dopamine. During adolescence, brain cells continue to bloom, with notable changes in the prefrontal cortex, which is involved in decision making and cognitive control, as well as other higher cognitive functions. Accordingly, I believe additional study is indicated regarding teen risk for developing a gambling addiction.
Help is Available Right Now! National Problem Gambling Helpline 1 (800) 522-4700 SAMSHA National Helpline 1 (800) 662-HELP
Written by Steven Barto, B.S., Psy., M.A. Theology
Since the birth of psychoanalysis, there has been a disconnect between psychology/psychiatry and theology. Freud’s worldview was that belief in God was nothing short of neurotic.
I HAVE BEEN ASTONISHED for years about the human condition. Too much violence, sadness, depression, anxiety, and angst among the population. For several years now, I have been studying the integration of psychology and Christian theology. Actually, my interest in psychology began with a need to understand my mess of a life. Today, I am embarking on a ministry of reconciliation, determined to help the downtrodden and the oppressed rise above their struggles with mental illness and addiction. From a personal perspective, these two concerns ruled in my life for decades: mental illness triggered substance abuse over and over; active addiction prolonged my mental illness. Although I received insight regarding my behavior, secular counseling failed to provide the right vision and tools I needed to break free. A three-year stint in state prison did not curb my appetite for drugs and alcohol; I continued getting high in prison. I was beginning to see the Groundhog Day quality of my life.
Integrating Psychology and Theology, one of myclasses at Colorado Christian University, peaked my interest. Fittingly, I had arrived at the point in recovery when I realized only Jesus could break the chains of drug abuse and mental disease. Moreover, I came to believe (at least for the Christian in crisis) that counseling alone often is not enough. I subscribe today to the adage, Counseling must always include discipling; and discipling must always include counseling. I noticed the fact that many Christians are embroiled in substance abuse, but this does not mean he or she is not saved or does not love God. During a 21-day stay at a rehab, I met a man who was the lead pastor of a church somewhere in the region. He was clean from drugs for 9 years. He relapsed on his drug of choice (crack cocaine) and lost everything. Whenever he shared he would say, “My name is Bill and I am a Christian in recovery.” He led some amazing late evening Bible studies which were well-attended by 5 others, including me.
A Legal Implication
In Nally vs. John MacArthur and Grace Community Church (1), 24-year-old Kenneth Nally committed suicide by shooting himself in the head with a shotgun. His parents filed a wrongful death action against Grace Community Church of the Valley, a Protestant Christian congregation located in Sun Valley, California, and four Church pastors, MacArthur, Thomson, Cory and Rea, alleging “clergyman malpractice,” specifically negligence and outrageous conduct in failing to prevent Nally’s suicide. A member of the Church since 1974, Nally participated in pastoral counseling at GCC prior to his death. The pastors vehemently discouraged him from receiving psychological or psychiatric care (despite a prior attempt at taking his own life by intentional drug overdose), failing to meet a standard of care for pastors, failure to secure proper psychological counseling training, and failure to disclose Nally’s true psychiatric condition to his treating psychiatrist and his parents.
The intent of this lawsuit was to define “duty of care” regarding pastors and their clients. The same dilemma presents itself in addictions counseling. Christian and secular counselors share the same desire—helping people overcome mental illness. Christian counseling is distinct from secular counseling in that it specifically incorporates the spiritual dimension when providing therapy. By using biblical concepts, Christian counselors can provide specific direction and accountability in accordance with core Christian principles. When, however, must a Christian counselor refer a church member to secular treatment? At the heart of most efforts to understand secular versus faith-based counseling is the essential theological and philosophical foundation, the unity of truth. This is often expressed as all truth is God’s truth. Although the unity of truth has been affirmed since the time of the early Christian church, this specific relationship has been classically applied to psychology.
A Persistent Disconnect
Since the birth of psychology, there has been a disconnect between psychology/psychiatry and theology. Freud thought belief in God was nothing short of neurotic. Yet he was curious, warm, and respectful of several clergy, and enjoyed having them as house guests. Entwistle quotes several entries from the private journals of Abraham Maslow that I found upsetting. Since my initial exposure to his Hierarchy of Needs, I have agreed with his theory. I learned later in life that my physiological needs were not consistently met by my then fifteen-year-old mother. There were serious frustrations of my safety and security needs, as well as esteem related matters. I believe much of my trouble was rooted in the frustration of critical elementary needs. Regarding Maslow, I was shocked to read his private bashing of religion. Entwistle warns it is dangerous when someone deliberately conceals his or her anti-religious bias (2). Not surprisingly, the issue of secular versus faith-based counseling falls on a continuum, with “extreme” beliefs at polar opposite. John MacArthur can be found at the very end of the scale toward biblical counseling, with virtually no room for compromise. What of psychology’s roots in philosophy and theology?
Wilhelm Wundt (1832-1920) began his career in psychology with experimental studies, hoping to understand the elements of thought and the mental elements that govern thought processes. According to Wundt, thought is comprised of sensations and feelings. “Sensations” come to us through the senses. In other words, our initial perception is the cause to our effect. All sensations are accompanied by feelings. He viewed the mind as active, creative, dynamic, and volitional. This gives us insight into similarities between psychology and theology. For example, ours is a “speaking” God, and we must be His “hearing” church. God is the cause and our response is the effect. Importantly, there is much that can keep us from hearing God: physical pain, anger, depressed mood, anxiety, selfishness, and so on. It is worth noting that successful ideas, no matter what their source, survive; unsuccessful ideas are cast aside. Even today, we see “schools of thought” labeled behavioristic, cognitive, psychobiological, humanist, etc.
René Descartes began with philosophy, focusing on the mind-body interaction. He noted that only humans possess a mind that provided consciousness, free choice, and rationality. He wrote, “Thus it follows that this ego, this soul, by which I am what I am, is entirely distinct from the body and is easier to know than the latter, and that even if the body were not, the soul would not cease to be all that it now is” (3). An aspect of theology presents itself in Descartes’ philosophy; our will can and should control our passions, so that virtuous conduct results. Such control, however, is far from perfect. He attempted to formulate a completely mechanistic explanation of man’s bodily functions. This was the dawn of both stimulus-response and behavioristic psychology. But his comparative study of the instincts of man and animal pulled his theory away from metaphysical and spiritual concepts. Regardless, Descartes is considered to be the father of modern philosophy in general and modern psychology in particular.
Søren Kierkegaard attempted to explain the meaning of human existence, freedom of choice, and the uniqueness of each individual. This is rudimentary existentialism identifies the most important aspects of humans—their personal, subjective interpretations of life and the choices they make in light of those interpretations. To me, this seems like a precursor to understanding worldview. No doubt Descartes’ exposure to his father’s theological teachings provided a foundation. His formal education included theology, literature, and philosophy. Hubben relates Descartes’ interpretation of man’s relationship to God to a lover’s experience. It is “…at once painful and happy, passionate but unfulfilled, lived in time yet infinite”(4). Renaissance humanism had four major themes: a belief in the potential of the individual, an insistence that religion be more personal and less institutionalized, an intense interest in the classics, and a negative attitude toward Aristotle’s philosophy.
Frederick Nietszche took an interesting view of human nature. His Apollonian aspect represents our rational side, our desire for tranquility, predictability, and orderliness. His Dionysian aspect represents our irrational side, our attraction to creative chaos, and to passionate, dynamic experiences. At first blush, these aspects line up with the duality of man’s behavior. Do not “just live” but live with passion; be willing to take chances. Nietzsche considered himself primarily a psychologist. To some degree, he, like Sigmund Freud, wanted to help individuals gain control of their powerful, irrational tendencies in order to live more creative, healthy lives. Nietzsche explored repression, which is a large part of Freud’s psychoanalysis. Nietzsche provided an example: “‘I have done that,’ says my memory.’ ‘I can’t have done that,’ says my pride'” (5). After much wrangling, memory wins out. Of course, Nietzsche gave absolutely no room for God in his theories. He said, “Is man just one of God’s mistakes? Or is God just one of man’s” (6). He famously said, “God is dead.” Perhaps today’s rejection of God and theology has more to do with the current atmosphere of moral relativism, secularism, and atheism than the grassroots relationship between theology and psychology.
In Part Five, I will present the major theories of personality development, comparing them to biblical theories of human behavior, the capacity to care for one another, free will, guilt and shame, and the concept of original sin. Also, I will discuss the similarities and differences between psychology and theology regarding human behavior. Christian theology is, after all, a branch of inquiry that—among other things—seeks to understand what it means to be human. But psychology, for the Christian, is infused with theological beliefs about our place in God’s world. I believe we can gain a more complete view of human behavior by drawing on both Christian theology and contemporary psychology. Yet, the caveat is that our theological and psychological perspectives can easily be hijacked, taking us down a troublesome path. Integration of Christian theology and psychology must be done in the interest of seeking God’s truth, recognizing His sovereignty over all that we do, and determine how best to relate Christianity and psychology.
(1)Nally v. Grace Community Church (1988) 47 Cal.3d 278, 763 P.2 948; 254 Cal.Rptr 97. (2) David N. Entwhisle, Integrative Approaches to Psychology and Christianity, 3rd. ed. (Eugene, OR: 2015), 198. (3) René Descartes, Meditations on First Philosophy, 2nd. ed. (South Bend, IN: University of Notre Dame Press, 1992), 21. (4) William Hubben, Dostoevsky, Kierkegaard, and Kafka (New York, NY: Macmillan, 1952), 24. (5) Frederick Nietzsche, Beyond Good and Evil (New York, NY: Oxford University Press, 1886, 1998), 58. (6) Nietzsche, The Gay Science (New York, NY: Oxford University Press), 5.
IN PART ONEOF THIS SERIESwe discussed the advent of social science, whose practitioners slowly changed the face of mental health counseling. Psychiatry stood as the primary specialty for treating psychiatric conditions such as bipolar disorder, depression, and anxiety. Psychiatrists typically do not engage in meaningful long-term clinical dialog. Instead, they prescribe psychotropic medications. Today, social workers, psychologists, and their ancillary workers, provide the majority of “talk therapy.” Notwithstanding the above, it was psychiatrists who were tasked with compiling data and establish a universal “code” for quantification, research, and billing purposes. Part Two showed the impact of the Enlightenment on virtually all aspects of life, characterized by skepticism toward religious dogma and other forms of traditional authority. Secularism and relativism began to creep into the discussion. Isaiah Berlin established an alternative movement in the late 1800s which he labeled Counter-Enlightenment. He attempted to challenge rationalism, universalism, and empiricism, objecting to these and other isms, saying they identify man as “mere machine” whose quest for reality is drastically limited to empirical interaction with nature.
Early practitioners thought experimental psychology was the best tool for getting at the basics of consciousness, but they believed “laboratory psychiatry” was useless for grasping the aspect of higher cognitive function. Wilhelm Wundt proposed that “sensations” (which occur when a sense organ is stimulated and impulses reach the brain) are are always accompanied by feelings. Arguably, attempting to isolate, grasp, understand, and write about “feelings” has always been a difficult task. Clinics and laboratories for the study of cognition flourished throughout Europe. Not surprisingly, psychology is a discipline rich in historical and philosophical roots. Many evangelical and fundamental pastors have disparaging thoughts regarding psychiatric and psychological treatment modalities. Although many people keep “faith” carefully segregated from the rest of their lives, I believe it is possible to establish and maintain productive links between psychology and Christian theology.
It helps to remember that “worldview” is a fundamental orientation of the heart, which is laid bare by our words and actions. Scripture notes that our heart is the central defining element of us as a person. Jesus said, “The good man out of the good treasure of his heart produces good, and the evil man out of his evil treasure produces evil; for out of the abundance of the heart his mouth speaks” (Luke 6:45, NRSV). What we hide in our hearts, what we have sown in its soil, eventually comes to the surface. Essentially, worldview provides a home for our philosophy on life. In its simplistic definition, worldview is a particular philosophy of life or conception of the world. We all have a worldview—the window through which we view the world, framed by the assumptions and beliefs that impact what what we experience on a daily basis. Without a doubt, our worldview shapes our philosophy of life.
“One of the most influential myths of the modern period has been the belief that it is impossible to locate and occupy a non-ideological vantage point, from which reality may be surveyed and interpreted. The social sciences have been among the chief and most strident claimants to such space, arguing that they offer a neutral and objective reading of reality; in which the ultimate spurious truth claims of religious groupings may be deflated and deconstructed in terms of unacknowledged, yet ultimately determinative, social factors” (2).
A Kaleidoscope of Views
Worldview brings with it many implications, which can admittedly muddy the waters regarding integration of psychology and Christian theology. When modernism failed to provide a beneficial philosophy of life in the face of war, poverty, famine, sickness, and unresolved racial tension, postmodernism attempted to replace knowledge with opinion or conviction. However, postmodernism had no advice on how to determine whether any given conviction is in some way better or more accurate than another. Again, our families, religious beliefs, academic experience, and media (especially social media) continue to influence us in ways of which we are unaware. It seems the key to unlocking our assumptions is having the humility and willingness to see them for what they are: that which we accept as true or as certain to happen, without proof. By definition, this “pursuit” of truth is a matter of epistemology (the theory of knowledge, especially how it is obtained). As we move forward in this series, we will explore how sociology, psychology, philosophy, and theology are crucial to integrating treatment modalities and Christian theology.
Saint Anselm of Canterbury said, “For I do not seek to understand that I may believe, but I believe in order to understand. For this I believe—that unless I believe, I should not understand.” It was thought that we could essentially become our own authority, knowing with absolute certainty (as God) the definition of right and wrong; in other words, the knowledge of good and evil. This is the very essence of our First Parents’ disobedience in the Garden of Eden (see Gen. 3:1-5). A hallmark of modernism is beliefin the human capacity to function as an independent authority. This orientation gave rise to another aspect of modernism: the myth of progress. Man became convinced that we can know things with God-like certainty (3). The brash disobedience of Adam and Eve caused a cosmic ripple effect for all of mankind. This “fallout” has shown itself in countless vain philosophies, which prove how we all thirst for what went wrong, whose fault it is, and how to fix it.
The philosophy of Søren Kierkegaard plays an important role in our quest to establish a viable integration of psychology and Christian theology. His “existentialism” stresses meaning, accompanied by freedom of choice and the uniqueness of each individual. He likened a proper relationship with God to a love affair, saying, “It is at once painful and happy, passionate but unfulfilled, lived in time yet infinite”(Hubben, 1952, p. 24). Kierkegaard initially rejected Christianity while in college, but changed his mind some time later. However, the Christianity he accepted was well outside the walls of the institutional church. He had no patience for dogma. The ultimate state of being for Kierkegaard was arrived at when we decide to embrace God and take His existence on faith, without needing a logical, rational, or scientific explanation of why or how one makes such choice. He was a proponent of the “leap of faith” approach to religion: the moment Abraham lifted the knife to kill his son on Mount Moriah captures what he meant by religious faith. He advised reading the Bible as we would read a love letter, letting the words touch us personally and emotionally.
These excursions into philosophy are meant to help us discover the roots of psychology. Friedrich Nietzsche considered himself a psychologist. His approach was comparable to Sigmund Freud. In fact, Freudian and Nietzschian psychology shared the goal of helping their patients gain control of their powerful, irrational impulses in order to live more creative and healthy lives. Nietzsche identified urges as das es, which is Latin for the id. He often discussed repression (a later cornerstone of Freudian psychoanalysis). For Nietzsche, internalizing the external standards of others was problematic. Likely, he saw this as counter to being authentic. So-called religious “followers” in his eyes become slaves to the one they follow. I will admit that this is an acceptable tenet of Christianity (see Rom. 6:20-22), but the focus is more on “dedicated follower” than slave. Nietzsche’s remark, “God is dead,” has been misunderstood and misused for generations. Actually, he believed God was dead because “we have killed him.” By we, he meant the philosophers and scientists of his day who stubbornly held on to empiricism, giving no credence to the metaphysical or spiritual realm. This left mankind with nowhere to turn for answers to the four great questions: (1) Where did we come from? (2) What is the meaning of life? (3) What is the basis for morality (right vs. wrong), and (4) Where do we go when we die? With the so-called death of God came the death of His shadow (metaphysics) as well.
This seems to leave mankind in a cosmic tabula rasa devoid of transcendental or spiritual forces to guide us. Yet, amazingly, Nietzsche said conviction is “belief in the possession of absolute truth on any matter of knowledge” (4). But it was his opinion that rationalistic philosophy, science, and the organized church discourage us from having a deep, personal relationship with God. Logic and facts have nothing to do with such a relationship, which must be based on faith alone. In this manner, Nietzsche believed we killed God, at least philosophically. Ultimately, when we accept God on faith, God becomes (for us and our encounter with Him) a living, emotional reality in our subjective experience. Although I believe in the ontological existence of God, I believe it is critical we understand that a “speaking God” needs a “hearing church.” It is our individual faith that quickens our spirit and allows us to experience God.
The Fork in the Road
David Entwistle notes that every branch of learning provides a unique view of God’s world and allows glimpses of His mystery. For the evangelical, fundamental Christian, psychology must be infused with a theological belief about our place in God’s world. Christianity is much more than theology; it is predicated upon a personal relationship with Christ as Lord, as rabbi, as redeemer. Of course, Christianity holds very specific beliefs as to the cause of human suffering. Admittedly, this causes Christian counselors to come to the table with certain assumptions. Pastors and church elders shepherd church members toward a maturity in Christ, as they should. Elders tend the flock in such a way that believers develop from spiritual infancy to full-grown Christ-likeness. Paul wrote in his first epistle to the Corinthians, “I fed you with milk, not solid food, for you were not ready for it. And even now you are not yet ready, for you are still of the flesh” (1 Cor. 3:2-3a, ESV). The word “milk” (Gr. gala) in the above Scripture passage means the basic, elemental teachings of Christianity first learned by new believers; the word “meat” (Gr. broma) denotes a deeper, more complete understanding and application of God’s Word.
What does reason have to do with faith? What does the intellectual have to do with the spiritual? What does philosophy have to do with Christianity? Tertullian summed up these questions when he asked, “What hath Athens to do with Jerusalem?”(5). Entwhistle noted “individuals who espouse a sacred/secular split in an attempt to preserve theological supremacy actually minimize the scope of God’s sovereignty” (6). This makes perfect sense. We cannot bifurcate God from His creation, or from our everyday existence. Unfortunately, it is not uncommon to encounter fundamentalist or evangelical pastors and teachers who claim that Christians must reject in total the “false doctrine” of psychology, and run from all manner of secularism in order to find health and healing in Christ. It is critical to understand the difference between “secular” life issues and secularism. As human beings, we need to avoid an “ivory tower” existence. We cannot deny non-religious, “lay,” or temporal orientations while we remain in an earthly body. Secularism is a worldview that is hostile to Christian theology. Entwhistle helps put this matter into perspective: “To think secularly is to think within a frame of reference bounded by the limits of our life on earth… to think Christianly is to accept all things with the mind as related, directly or indirectly, to man’s eternal destiny as the redeemed and chosen child of God” (7) (italics mine).
In Part Four I will show how counseling provided to Christian believers in crisis by Christian practitioners and clergy must include discipling; and inversely, Christian discipling must include counseling. Further, I will introduce the concept that extremism regarding this continuum is destructive. So-called secular combatants see religion as incompatible with mental health and intellectual discourse. Christian combatants see psychology as an enemy which is opposed by sound doctrine, and they see the use of psychotherapy (and psychotropic medication) as incompatible with, if not unnecessary for, those who live victorious Christian lives. I will provide insight on the theory of “nouthetic counseling” (Gr. noutheteo, “to admonish”), which is a form of evangelical Protestant pastoral counseling based solely upon the Bible and focused on Christ. It repudiates mainstream psychology and psychiatry as humanistic, fundamentally opposed to Christianity, and radically secular.
I will present the case of Nally vs. John MacArthur and Grace Community Church. The case presents a variety of issues concerning a lawsuit for wrongful death by the parents of a suicide victim against Grace Community Church’s pastoral counselors. On April 1, 1979, 24-year-old Kenneth Nally committed suicide by shooting himself in the head with a shotgun. His parents filed a wrongful death action against Grace Community Church of the Valley, a Protestant Christian congregation located in Sun Valley, California, and four Church pastors, MacArthur, Thomson, Cory and Rea, alleging “clergyman malpractice,” specifically negligence and outrageous conduct in failing to prevent Nally’s suicide. A member of the Church since 1974, Nally participated in pastoral counseling at GCC prior to his death. The pastors vehemently discouraged Nally from receiving psychological or psychiatric care (despite a prior attempt at taking his own life by intentional drug overdose), failing to meet a standard of care for pastors, failure to secure proper psychological counseling training, and failure to disclose Nally’s true psychiatric condition to his treating psychiatrist and his parents.
The case of Nally vs. Grace Community Church puts at our feet the issue of integrating Christian theology and psychology. Pastors at GCC told Nally that his attempted suicide by overdose was a sign that God was punishing him. MacArthur and his pastoral staff told Nally his problems were rooted insin, and that his mental illness could be properly treated by relying solely on biblical principles. The irony is not lost on me that psychology literally means “the study of the soul.” I will present the argument that psychiatric care must never be dogmatically withheld from a church member who is contemplating, or who has attempted, suicide.
Footnotes and References
(1) James Sire, The Universe Next Door: A Basic Worldview Catalog, 5th ed. (Downers Grove, IL: InterVarsity Press, 2009), 20. (2) Alister E. McGrath, A Scientific Theory: Nature (Grand Rapids, MI: Eerdman’s Publishing, 2009), 17. (3) David N. Entwistle, Integrative Approaches to Psychology and Christianity, 3rd. ed. (Eugene, OR: Cascade Books), 2015. (4) Friedrich Nietzsche, Human, All Too Human (Germany: 1878). (5) Tertullian, The PrescriptionAgainst Heretics 7 (New York, NY: London Society for Promoting Christian Knowledge, 1914), 45. (6) Entwhistle, Ibid., fn3, 8. (7) Ibid., 9.
By Nora D. Volkow, M.D. Executive Director, National Institute on Drug Addiction
Original Post April 20, 2020
Each day in 2018, an average of 185 people in the United States died from a drug overdose (1). In fact, recent declines in U.S. life expectancy are being attributed to direct and indirect effects of alcohol and drug use disorders. Expanding the number of people receiving evidence-based addiction treatment is crucial for reversing these trends. But among the many challenges in delivering appropriate care to the nearly 20 million people in the United States with substance use disorders is the chilling effect of stigma. Stigma not only impedes access to treatment and care delivery; it also contributes to the disorder on the individual level. Stigma associated with many mental health conditions is a well-recognized problem. But whereas considerable progress has been made in recent decades in reducing the stigma associated with some psychiatric disorders such as depression, such change has been much slower in relation to substance use disorders (2). One obstacle is that this stigma has causes beyond those that apply to most other conditions. People who are addicted to drugs sometimes lie or steal and can behave aggressively, especially when experiencing withdrawal or intoxication-triggered paranoia. These behaviors are transgressions of social norms that make it hard even for their loved ones to show them compassion, so it is easy to see why strangers or health care workers may be rejecting or unsympathetic.
Tacit beliefs or assumptions about personal responsibility — and the false belief that willpower should be sufficient to stop drug use — are never entirely absent from most people’s thoughts when they interact with someone with a drug problem. Health care professionals are not immune to these assumptions. Indeed, they may hold stigmatizing views of people with addictions (3) that may even lead them to withhold care. In emergency departments, for instance, health care professionals may be dismissive of someone with an alcohol or drug problem because they don’t view it as a medical condition and therefore don’t see its treatment as part of their job. People who inject drugs are sometimes denied care in emergency departments and other hospital settings because they are believed to be drug-seeking. In part, the difficulty reflects continued resistance to the idea that addiction is a disease. Drug use alters brain circuitry that is involved in self-regulation and reward processing, as well as brain circuits that process mood and stress. For a person with a serious substance use disorder, taking drugs is no longer pleasurable or volitional, for the most part, but is instead a means of diminishing excruciating distress and satisfying powerful cravings — despite often devastating consequences. Some people are more vulnerable than others to developing a substance use disorder because of a genetic predisposition, adverse social environmental exposures, traumatic life experiences, or other factors. To recover, they often need external help and support — evidence-based treatment, with medication when possible. Unfortunately, their encounters with health care providers may serve only to reinforce their disorder.
While visiting a makeshift heroin “shooting gallery” in San Juan, Puerto Rico, I urged a man who had what appeared to be a massive abscess in his leg to go to an emergency room to get it treated. He refused to even consider it, and told me that when he had previously sought medical help, he had been so badly mistreated that he was frightened of returning. He would rather jeopardize his life or risk a leg amputation than endure being dismissed as a “drug addict.” Stigma not only impedes care delivery, it also most likely causes us to underestimate the burden of substance use disorders in the population. But stigma plays an even larger role in this crisis, one that has been less discussed: when internalized, stigma and the painful isolation it produces encourage further drug taking, directly exacerbating the disease.
Ever since the “Rat Park” experiments of the 1970s, which showed that animals housed in enriched environments with access to other rats self-administered morphine much less frequently than those housed in isolation, social isolation has been known to play a crucial role in vulnerability to and difficulty of recovering from addiction. Research on social reinforcement and its neurobiologic mechanisms has illuminated the links between stigma and drug use. For one thing, there is substantial overlap between the neurologic underpinnings of drug rewards and those of social rewards. Research by Naomi Eisenberger at UCLA has found that social pain is processed in some of the same brain areas that process physical pain and is quelled by pain relievers (4).
Strikingly, a recent article by Venniro and colleagues reported that when given a choice between self-administering a drug and interacting with another animal, methamphetamine- or heroin-dependent rats chose the social interaction. However, when they were punished for the social choice with an electric shock before the interaction, the rats reverted to choosing the drug (5). In a sense, stigmatizing treatment of people who use drugs, such as ignoring or rejecting them, may be the equivalent of an electric shock in the cycle of drug addiction: it’s a powerful social penalty that spurs further drug taking. Stigma is not the only factor impeding adequate treatment of people with substance use disorders, but if we are to achieve the public health goal of getting and retaining many more people with substance use disorders in treatment, we have to ensure that the health care system will not penalize people who are addicted to drugs for their condition. Among other steps, improving treatment will require training physicians, nurses, nurse practitioners, physician assistants, and emergency department staff in providing compassionate care to patients who may display the difficult, sometimes frightening behaviors associated with drug addiction and withdrawal.
It is also necessary to promote awareness of addiction as a chronic relapsing (and treatable) brain disease. This effort should include promoting understanding of the disease’s behavioral consequences as well as of the factors that make certain people particularly vulnerable. Susceptibility to the brain changes leading to compulsive substance use is substantially modulated by genetic, developmental, psychiatric, and social factors, many of which are out of the person’s control. Given the gravity of the current overdose crisis, it is urgent that we conduct research aimed at overcoming stigma toward people with addiction. Yet even in the absence of research, common sense can guide us: respect and compassion are essential. People working in health care should be made aware that stigmatizing people who are addicted to opioids or other drugs inflicts social pain that not only impedes the practice of medicine but also further entrenches the disorder.