The Stigma of Addiction

Saturday, June 15, 2024

Primary Blog/clinical issues/The Stigma of Addiction

Like epilepsy, addiction just is. Yet the effects of stigma are still prevail. Shame and secrecy govern every addicted family system, and are barriers the addict and all significant others must confront and overcome in order to heal. Granted, no one wants to have a disease. But the point is what happens when you have a disease. Recognition and admission are pre-requisites to getting the necessary help or treatment. Stigma makes compassion towards oneself and each other a huge hurdle, accepting one’s humanness out of reach.

Those who don’t understand that a disease “just is,” will likely consult with others who tell them that everything is okay, just as Mama did with the doctor who assured her that “kids have them all of the time.” Without being aware, we have a way of relaying the message, “Please tell me there is nothing wrong.” Most people are inclined to oblige, inadvertently willing to distort the facts so to not blemish a prettier picture.

Claudia Black, the acclaimed authority on Adult Children of Alcoholics, wrote in her book, It Could Never Happen to Me, discusses the ‘Don’t Talk’ rule that all members in an alcoholic family abides by and that comes from the stigma attached to alcoholism. She uses the example of a young child asking his/her mother, “What’s wrong with daddy?” when he is lying on the couch in a near comatose state from alcohol intoxication. And, mother answers matter of factly, “Daddy is sleeping,” as if s/he was observing nothing out of the ordinary and there was no reason to be concerned. This misrepresentation, she explains, is at the bare minimum confusing for the child as it invalidates his/her concern. The children in such a system are trained to pretend that what they see is not what they see, but is something else. They get trained to think and communicate falsely. Yet, the undercurrent of shame, concern and confusion remains as they can’t help but notice the incongruity. They intuitively put one and one together and get the message that no one is supposed to know; not just that Daddy was drinking, that he “sleeps a lot,” has a problem or disease, and needs help. They never really find out the truth because it remains concealed from them; they know something is wrong, but don’t know what the problem actually is.

Clinical Issues and Counter-transference

The influence of stigma and depth of shame can be and often is underestimated by treatment practitioners. This is especially relevant considering the variety of related clinical issues; those being preparedness for dealing with the many layers of stigma-based shame triggered when a stigmatized condition is identified, as in the case of addiction for example – beginning with having problems, being an addict, needing help, not having adequate will power, and for the hurt caused to oneself and others; all of which are major hurdles throughout recovery.

For example, a patient who had three years of sobriety reportedly felt pangs of remorse or shame when a friend offered him a “toke” on a joint and he declined the offer. Any environment or group atmosphere where recreational using is ‘desirable’ has the potential to trigger shame, regardless of how long the recovering person has maintained sobriety. Feeling good or shame-free remaining abstinent can only occur in a stigma-free situation, i.e. being with other sober people and when sobriety is the norm.

Homophobia and Intimacy

The following is my own story of revelation and transformation gained from my self-analysis and willingness to be honest with myself. While I was going through the process, it felt painfully difficult because I wanted to see myself as not being homophobic. But the experience made real a powerful lesson learned: Homophobia comes at the expense of intimacy, intimacy in both professional and personal contexts.

I’m Daniel. I’m heterosexual and (was) homophobic.

I can recall my high school days when gays were “fags,” “pussies,” “dykes,” freaks, outsiders, non-entities, people you’d always get support for abusing, the safest of scapegoats. I wondered why I (and others) invariably reacted with avoidance, indifference and disdain., whether we were aware of it or not. I didn’t understand how I was different or better. Certainly, I wasn’t a pillar of normalcy, yet I was obviously better off than they were.

It wasn’t until I was a freshman in college that I learned about stigma in a sociology class. A stigma is a visible or known attribute that relegates a person to a substandard or less desirable category of people. This person is disgraced, treated as weak, evil, immoral, defective, incapable and unworthy. But at the time, I hadn’t made the connection that gay people were stigmatized, probably because “out of sight” meant “out of mind” to me.

It wasn’t until graduate school that I realized I was homophobic. It was there I first heard the term. My understanding was that it had to do with the stigma attached to being gay, an aversion to same gender sex accompanied by a devaluation of the person.

My homophobia was evident in the ways I reacted to the idea of men having sex with other men, women having sex with other women; of a man wanting to have sex with me and of me having sex with a man. I was aware of an ingrained, almost automatic fear and revulsion, and was able to talk about it. More alarming, however, were its unconscious manifestations – how my homophobia influenced my behavior whenever I was with someone who was gay. I acted respectfully and even honestly. I was able to laugh with the person, ask for help and offer help. I knew how to be nice. But then, after we parted, it seemed I was relieved.

As I developed more understanding of my homophobia and homophobia in general, I saw there was a distinction between blatant and sophisticated homophobia. When it’s blatant, homophobia usually comes across as ignorance or malevolence. When it’s sophisticated, the person’s attitude is more subtle; pretension, concealment and denial are involved.

The question I eventually had to ask myself was how emotionally close can or would I allow myself to get to someone who is gay. Although I wanted to see myself as someone who treats every person as equal, I wasn’t sure I was capable of doing so. Since my contact with the gay population was minimal, I hadn’t explored this question much further.

It was when I decided to get more involved professionally with the gay population that I was, once again, confronted by this question.

I was putting together my first gay men’s Dating to Relate workshop, which was about developing dating and intimacy skills. Up to this point I had done only heterosexual groups and workshops.

One of the participants told me he had AIDS and wanted me to call the other group members to make sure his having AIDS was okay with them. I was under the impression that if someone is not actually sick, they probably don’t have AIDS, they’re merely HIV-positive. After I had spoken to the other group members, I let him know that none of them had a problem with his being HIV-positive. He later called back to tell me that my ignorance about HIV and AIDS made him feel unsafe being in a therapy group with me as the leader.

During the course of conversation, it became clear to me that I was not only dealing with someone who was gay, but someone with a disease, someone who could get sick and die. Suddenly I felt exposed and vulnerable. It dawned on me that I had kept myself insulated or emotionally removed from the reality of AIDS, despite all the attention it received in the media. Why was AIDS something that wasn’t real to me until it was in my face? Was it my homophobia? Or did it have more to do with my aversion to disease and death? Either way I had to respond to him. He wanted my assurance that I understood his considerations and he responded with a decision to be in the group.

This conversation changed me. I got much closer to him than I had anticipated. I found myself getting intimately involved with a gay man who has AIDS and knew I was going to get even more involved with him during the group. I accepted the fact that I couldn’t take his AIDS away from him, that he and AIDS were a package deal. In that moment, I also realized that his being gay was the same thing; it’s impossible to totally accept someone who is gay without accepting his or her sexual orientation.

This was just the beginning of my metamorphosis.

During the workshop, it became apparent that, just like me, these gay men were also homophobic. But unlike me, their fear and revulsion were directed at themselves and profoundly affected their experience in relationships.

Not only was their homophobia an obstacle with which they had to contend, they had to overcome the kind of deep, silent pain that stigmatized people suffer when they know that what they are at their core is unwanted, unworthy and doesn’t belong. Several of them discussed homophobia as a determining factor in their emotional and sexual development, and as an impediment in developing sexual and intimate relationships.

One of the group participants noted, “Growing up, being gay was the absolute worst thing in the world. It was the lowest low of human beings. Gay sex was what distinguished me from other people. It was taboo for me to express my sexuality. There were no role models around me. I didn’t receive any positive messages. I didn’t know any gay people. There were no gay people in my family. I had no gay friends. To me, gay sex was perverted, wrong, dirty and awful. The anonymous sex I had, which was about 95% of all the sex I had was a playing out of society’s expectations of how I should have sex. And I did a remarkably good job. The only options I had were furtive and shameful. Even after I came out, this pattern was so ingrained in me it persisted, that all I could have was that kind of sex and part of me still believes that gay sex should be anonymous, that it belongs in bathrooms or the park.”

Someone else added, “And it’s part of what made the gay community such a fertile place for HIV to land. Our culture doesn’t support monogamous relationships between the same sexes. It supports those kinds of encounters: bath houses, parks, bookstores, gas stations, where we don’t know our partners. We don’t like what you do, but if you’re going to do it, keep it in sleazy places where we don’t have to see it or know about it. If it were okay to make a commitment to another person, anonymous sex wouldn’t be as prevalent as it is and nor would the gay population be such a hotbed for sexually transmitted diseases.”

As we discussed the issue of homophobia further, it became apparent that homophobia isn’t merely a part of our social conditioning; it exists in our families as well, where it is probably the most well-disguised. It was unanimously accepted among the group members that being gay or living a gay lifestyle was not an option for them. Whether the messages were implicit or explicit, they felt being gay was a source of embarrassment and disappointment to their parents.

These men taught me a lot about something I’d had no experience of, namely, what it’s like to grow up in an extremely homophobic society. At the same time, however, I was deeply disturbed. I couldn’t help but wonder, What if most people are like how I used to be: uninformed, afraid and judgmental? How many people really want to know what it’s like being gay? What it’s like growing up in a culture that rejects and denies your very essence, what it’s like to have parents who can’t and in many cases never will accept you, what it’s like to be different from everyone else, to live in secrecy, to be hated and mocked so long that you actually believe you are incapable if intimacy, and as a result, resort to anonymous sex as the only available means for sexual/human contact, yet are like everyone else, yearning for love?

Stigma poses potential counter-transference issues for the helping professional who underestimates or is unaware of its presence. Clinicians are human beings, not immune or impervious to stigma’s far-reaching effects. Socially indoctrinated judgements can, and often do find their way into the clinician’s head. For example, the professional might be unaware the s/he sees an addicted patient in a less desirable light, as opposed to someone in the throes of a disease. The counsellor might not have any idea that his/her level of compassion is diminished and outlook dimmed. The counsel or might look for other causes; miss the primary problems staring him/her in the face, and focus instead on secondary ones. If unaware, the tendency would be to shy away from the diagnosis of addiction so as not to have to deal with all of the uncomfortable ramifications.

While the idea here is for the clinician to work towards minimizing counter-transference by examining the impact of stigma on him/herself, doing so can pose an interesting dilemma. When the norm for therapists is to always strive for unconditional acceptance of the patient – not having any judgements—realizing one’s own deep dark thoughts, i.e. one’s homophobia runs counter to the ideal of being a good therapist, can become a shame inducing experience in its own right. By rejecting or denying one’s judgements or other stigma-related reactions, the clinician is at risk of revealing the damaging judgements s/he is harboring, inadvertently reinforcing the patient’s shame by mirroring another human caught in the stranglehold of stigma.

Additionally, if the issue of stigma is not adequately confronted and the counsellor remains insulated from his/her own reactivity, s/he will not be tuned into his/her patient’s emotional experience, let alone, level of internalized shame. It’s absolutely necessary for the helping professional to be aware of the social climate, and reckon with the fact that s/he could be at the effect of the prevailing stigma-based norms, i.e. standards for desirability.

The clinician must understand that an addict is the stigma incarnate. Being addicted is ‘undesirable,’ representing everything one is not supposed to be. The addict can no longer adhere to the standard of desirability or play the game. S/he reflects back to the therapist only the starkest of visions of him/herself, one’s s/he is not accustomed to or preferred. The more together the act, the easier it is to foster the illusion of competency, as opposed to exposing our humanity.

As the clinician becomes more aware of the powerful effects of stigma, s/he will be able to incorporate the disease concept into his/her work. The disease concept is the counter-balance to stigma as it serves to humanize, de-mystify, enlighten and objectify. Loss of control, impaired judgement, less than desirable behavior, destructive behavior, relationship breakdowns, unemployment, bankruptcy can be understood to be natural consequences of the disease. It makes it easier to respond compassionately. There is a consensus that the addict shouldn’t be shamed because s/he is sick, nor because s/he is human!


Night, Mother, Marsha Norman
Shame, The Power of Caring, Gershen Kaufman
​Stigma, Irving Goffman

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Hi, Daniel

Daniel A. Linder is a licensed Marriage & Family Therapist, Relationship Therapist and Trainer, an Addiction and Intervention specialist, with nearly four decades of experience working with individuals, couples and families.

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