Ending Stigma: After the Brain Disease Strategy Fails

Editor’s note: First in a 3-part series.

The brain disease model of addiction is both a scientific and social construct. The scientific ideas are best debated by those conversant in the relevant genetic and neuroscience research. The social aspect of the disease model warrants broad discussion. Its goal is to end the stigma of addiction, which is critical since stigma suppresses access. Yet a new, major study suggests it is failing in this social role.

The survey findings by Shatterproof are dismal:

Despite decades of public education, 75.2% of the public do not believe that a person with a [substance use disorder] is experiencing a chronic medical illness like diabetes, arthritis, or heart disease. Additionally, 53.2% of respondents hold the beliefs that SUD is caused by a person's bad character. (page 3)

Shatterproof launched a multifaceted movement in 2020 to end stigma. Like most organizations, it expected the brain disease model to be a cornerstone of its work. The stigma of addiction may be more severe than any, and a medicalized approach has been used to overcome this stigma longer than most. Yet these survey findings suggest that this message has not been accepted by the public.

These findings will not discourage those committed to a brain disease model. They not only believe in its validity but in the lack of better alternatives. Unfortunately, the question of the validity of the model is often based on confusing its scientific and social aspects. It matters little if the disease model is scientifically correct if it fails in its vital anti-stigma role. The two issues are related but separate.

There are two good alternatives. We can better educate people about addiction treatment, and we can frame addictive disorders in the context of normal human experience. We need the public to better understand the valuable biopsychosocial solutions available today. They also must see that while clinical disorders are qualitatively different, they fit with our common struggle to change unhealthy behaviors.

Let us normalize the full continuum of behavior. The medical model relies on diagnostic separation of clinical disorders from non-clinical states. Yet all such behavior constitutes human experience. We can differentiate safe, risky, and addictive use of substances, but those differences do not eliminate our common humanity. Empathy springs more readily from a sense of commonality than difference.

People do not understand the repetitive, self-destructive nature of addiction, and they have little idea how it can be effectively treated. The media bombard us with stories of failure and resistance to change. Yet we all can understand the universality and frustration of changing unhealthy behavior. Addiction involves extreme behavior, but behavior change is still fundamentally a human problem.

The public should know a few key points. People using highly addictive substances like opiates can be detoxed and maintained physically with effective medications. We are then able to address addiction with a combination of psychological methods like relapse prevention skills and social methods like peer support meetings. Let us replace a remote model of disease with a tangible model of treatment.

Experts have reframed addiction as a chronic disease like diabetes. Many parallels can be drawn between the two, but the role of behavior is a crucial one. People struggling with each must find ways to sustain behavior change. One group may focus on eating and exercise, the other on substance use. Both could benefit from destigmatized access to our behavior change experts, psychotherapists.

Medicalizing problems produces powerful treatments. Yet we can appreciate valuable treatments for addiction without promoting the biomedical model as a social ideology replacing the moral model of addiction. Furthermore, cultural beliefs may be only one front for ending stigma. Stigma is a social phenomenon and defeating it will probably require strategies for social and institutional change.

A group of scientific experts warned us earlier this year that it would be dangerous to deny the brain disease model of addiction. They fear rejection of this model “contributes to reducing access to healthcare and treatment.” Their article is a strong scientific defense of the disease model. However, their thoughts on access and the social function of the model stem more from hopeful logic than from any data.

We now have the Shatterproof evidence, and it does not fit with their logic. Let us reformulate our strategy and coalesce our forces. The medical model has been utilized in a disorder-specific way to fight stigma, with independent fights related to mental illness and addiction. We can gain power through a unified campaign against society’s shaming of deviant behavior.

Let us replace shaming with a positive message that builds public enthusiasm for our treatment capabilities. Helping people with behavioral health disorders relies on tools that are similar to those for promoting healthy, productive lives. Regardless of the issue, we all manage thoughts, feelings, and behaviors to change. We all confront vulnerability. Let us defeat stigma together.

Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.

The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.