This article originally appeared on at WSSCSW.org

Stigma and shame are favorite topics of discussion in addiction circles. They are two sides of one coin: stigma resides within society and  shame is its internalized shadow, lurking deep within the person with the addiction. Addiction providers, myself amongst them, are always wondering how we can “end the stigma” of addiction and how we can dislodge the shame that sabotages treatment for our clients. Why does such a virulent strain of shame so universally afflict people with substance use disorders? How can I, as a therapist and an advocate for systemic change, work to diminish the power of shame and stigma for people suffering with addiction?

Renowned trauma therapist Janina Fisher believes shame comes from a fear of rejection. Speaking at a recent conference, she demonstrated the posture of shame for her audience: chin to chest, shoulders slumped, eyes cast down. In the animal kingdom (and we are animals too), it’s a posture of submission, useful in evoking generosity in the other: either pity or empathy, or forgiveness. The tendency towards shame resides in us to serve a purpose, securing our place in relationship, family, or community when those bonds are threatened. I remember the first time I saw this shame posture in my toddler. I scolded him for something unmemorable and his whole body slumped like a rag doll as he fell to his knees, his shoulders curling around his thighs. I remember the weight of him limp in my hands as I tried to lift him to look at me. His eyes would not meet mine. I was instantly distraught – any annoyance I had while reprimanding him evaporated.  In its place was a desire to pull him close, reassure him and mend the tear in the bond between us. His shame was immediately effective at evoking my forgiveness. 

Addiction is brutal on relationships. Often, as the substance use demands more and more dedication, the addicted person functions less and less elsewhere, not only at work or school but as a friend, partner and parent. Loving family members may pick up the slack, over-functioning for the addicted person, creating an imbalance which breeds resentment in the family. Finding it difficult to say no to overwhelming needs and requests, loved ones feel manipulated and unappreciated. The relationship is strained by the demands of the addiction. 

Recognizing shame as a fear of rejection makes sense when you consider the risk to an unbalanced relationship. Fear of rejection is made worse by the narrative of detachment that dominates advice to friends and family of people with substance use disorders. When you have a life-threatening disorder that seems to have really gotten the better of you, the risk of being ostracized by your support system is terrifying. Of course everyone benefits from having boundaries in relationships, and has a right to say “no” to help they don’t want to give. But this refrain about detachment is unique to addiction, even though loving someone with depression, dementia, traumatic brain injury or PTSD, can be equally exhausting.

“Kick them out!”

“Quit enabling!”

“Detach!”

“Let them hit rock bottom!”

These are the chorus lines of an anxious song, lines sung to every person who loves an addicted person. The sentiment that family involvement and closeness is damaging to people with addiction extends beyond the family into the treatment rooms. Or maybe it’s the other way around. Did the mindset originate in the treatment rooms and then infect the family? What better metaphor for familial detachment could there be than termination from treatment?

Addiction is the only disorder I can think of in which symptomatic patients who are having trouble finding remission are terminated from care rather than given more – or different - care. Certainly someone who wants to stop attending group because abstinence is not currently their goal, or wants to stop therapy (especially for trauma) because it’s too painful, inconvenient or unhelpful, should have the right to stop. But I am not talking about that; I am thinking of people who want help changing their relationship with substances but have not yet achieved their goals of abstinence or reduced substance use. 

I am thinking of the person whose emotional or physical discomfort drove them back to the street after 24 hours of medically supervised detox, whose motivation returns but is then refused re-entry into treatment because “We aren’t a revolving door.” I am thinking of the person who is asked to leave out-patient group despite months of success at abstinence from heroin because their  urine screens are positive for marijuana. I am thinking of the person who wants to reduce their problem alcohol use, but won’t be allowed into a treatment group because they can’t or won’t agree to abstain completely. I am thinking of the person in rehab who leaves AMA with urges to use that feel insurmountable, and returns within hours of relapsing, remorseful and ready to recommit to treatment, only to be asked to pack a bag and leave. 

Journalist Johann Hari proclaimed in his popular TED Talk that “The opposite of addiction is not sobriety; the opposite of addiction is connection.” While his may be an overly simplistic view of the complexity of addiction, it’s a useful idea that resonated with millions of viewers. Hari’s Ted Talk came on the heels of Dr. Gabor Mate’s best seller on addiction, “In the Realm of Hungry Ghosts.” Dr. Mate urges us to ask not “why the addiction?” but “why the pain?” Mate would say that the pain of people with addictions almost always comes from attachment trauma – rejecting or abusive early relationships. While his theory may be just as narrow as Hari’s, both Mate and Hari recognize of the role of connection and relational attachment in addiction, and it has struck a  chord with people. 

What might it look like if we truly recognized the power of shame in addiction – the fear of rejection and disconnection? What would empathy and connection, as a response to relapse, look like in the context of addiction treatment? 

I dream of the day when we pull people closer into therapeutic care when they are symptomatic rather than cast them out; when we spend more time in counseling rooms creating a safe space for vulnerable self-disclosure about patients’ use rather than spend energy rooting out hidden substance use; when we use words like person-, patient-, client-, father-, woman-“with a substance use disorder” instead of addict, alcoholic, crack-head or junkie; when we stop urging families to “Kick ‘em out and let them hit bottom” and instead support families with quality, accessible, affordable care for their loved ones (and maybe even a casserole or a card);  when we let each family identify their own limits of closeness or support; when we provide “caregiver support groups” for families of people with substance use disorders to learn self-preservation skills and limits, rather than “co-dependency” workshops that preach detachment and tough love. As long as we keep rejecting people with substance use disorders, we should not expect to make much progress in reducing stigma and healing shame in people with substance use disorders.