Addiction and Pastoral Care

By Sonia E. Waters and John Swinton

A timely resource treating addiction holistically as both a spiritual and a pathological condition

Substance addictions present a unique set of challenges for pastoral care. In this book Sonia Waters weaves together personal stories, research, and theological reflection to offer helpful tools for ministers, counselors, chaplains, and anyone else called to care pastorally for those struggling with addiction.

Waters uses the story of the Gerasene demoniac in Mark’s Gospel to reframe addiction as a “soul-sickness” that arises from a legion of individual and social vulnerabilities. She includes pastoral reflections on oppression, the War on Drugs, trauma, guilt, discipleship, and identity. The final chapters focus on practical-care skills that address the challenges of recovery, especially ambivalence and resistance to change.

• Language: English
• Publisher: Eerdmans
• Release date: Feb 5, 2019
• ISBN: 9781467452694

Sonia E. Waters

Sonia E. Waters (1972–2023) was associate professor of pastoral theology at Princeton Theological Seminary. An Episcopal priest, she served as a volunteer chaplain at a local treatment center and was involved in recovery activities in the Princeton area. 

Book preview

Addiction and Pastoral Care

Sonia E. Waters

WILLIAM B. EERDMANS PUBLISHING COMPANY

GRAND RAPIDS, MICHIGAN

Wm. B. Eerdmans Publishing Co.

4035 Park East Court SE, Grand Rapids, Michigan 49546

www.eerdmans.com

© 2019 Sonia E. Waters

All rights reserved

Published 2019

25 24 23 22 21 20 191 2 3 4 5 6 7

ISBN 978-0-8028-7568-6

eISBN 978-1-4674-5269-4

Library of Congress Cataloging-in-Publication Data

Names: Waters, Sonia E., 1972- author.

Title: Addiction and pastoral care / Sonia E. Waters.

Description: Grand Rapids : Eerdmans Publishing Co., 2019. | Includes bibliographical references and index.

Identifiers: LCCN 2018043572 | ISBN 9780802875686 (pbk. : alk. paper)

Subjects: LCSH: Substance abuse—Patients—Pastoral counseling of. | Drug addicts—Pastoral counseling of.

Classification: LCC BV4460.3 .W38 2019 | DDC 259/.429—dc23

LC record available at https://lccn.loc.gov/2018043572

Contents

Foreword by John Swinton

Acknowledgments

Introduction

Addiction across the Board

Addiction Organized

Terms and Conditions

1.Addiction as Soul-Sickness

Addiction, Relationality, and Soul-Sickness

How We See Addictions: A Brief History

Limits of the Moral and Medical Models

The Emergence of Addiction

Symptoms of the Sickness

Desire, Pleasure, and Soul-Sickness

The Framework of a Soul-Sickness

2.This Is Your Brain on Drugs

Drugs Inside and Outside the Self

The Rewiring of the Brain

Your Mind Is an Unsafe Neighborhood; Don’t Go There Alone

The Progress into Possession

Chronic Stress in Addiction

Excursus: Porn Addiction

The Brain in Pastoral Care

3.Addiction, Attachment, and Trauma

Attachment and Self-Regulation

Resistant, Avoidant, and Disorganized Attachment Relationships

Childhood Trauma and Disorganized Attachment

Post-traumatic Stress Disorder

Excursus: Eating Disorders

Putting the Pieces Together

Christian Practices of Self-Regulation

A Slower Resurrection

4.Addiction and Social Suffering

Racism, Homophobia, and Distress

Social Stress and the Crossover Effect

Socioeconomic Insecurity

The War on Drugs

Social Sin in Pastoral Care

5.Soul-Sickness and the Legion

The Social Demoniac

Bargaining with a Demon

Healing and Restoration

The Soul in Soul-Sickness

Untangling the Demoniac from God

Meaning-Making through Moral Complexity

Incarnational Grace

6.Motivational Interviewing and Change

The Balancing Act of Change

Intrinsic Motivation and Cultural Values

FRAMES Brief Intervention

FRAMES Feedback and the Elicit-Provide-Elicit Model of Intervention

Excursus: The Loved Ones of a Legion

Pastoral Care and the Self

7.Moving into Change

Encounters with Change

The Precontemplation Stage

The Contemplation Stage

The Preparation Stage

The Action Stage

Maintaining Recovery

Relapse Prevention

Supporting Spiritual Growth

Excursus: Mental-Health Conditions

Opening to Change

Notes

Bibliography

Index of Authors

Index of Subjects

Index of Scripture Citations

Foreword

Addictions are complex and perplexing. They are made up of a confusing combination of biological, psychological, sociological, relational, and spiritual components, all of which coalesce to shape and form the life experiences of those who find themselves trapped within any given addiction. The complexity of addictions tempts us towards simplicity. "Addiction is nothing but a manifestation of sinfulness and selfishness. Addiction is nothing but disease processes within the brain. Addiction is nothing but misplaced desire." Human beings like to try to explain difficult phenomena. If we can explain something we can control it. If we can control it, it is no longer a threat. Simplification and reduction may make for comforting forms of explanation, but in so doing they risk masking the complex reality of the phenomenon and closing down potentially important areas for reflection and intervention. One of the main contributions of this book is to help us recognize the need for an interdisciplinary approach to addictions that holds on to the crucial realization that acknowledging the complexity of addiction is vital for authentic understanding and faithful intervention.

Addictions carry deep moral connotations that are highly significant in terms of understanding, reaction, and response. In her work on the meaning of illness, Susan Sontag pointed us towards the significance of metaphor for understanding illness.¹ Illnesses such as cancer and AIDS, she argued, are not like influenza. Their meaning is not confined to their biomedical origins. Rather, they are very much social diseases that are deeply impacted by cultural meanings. As such they have a problematic tendency to draw to themselves certain metaphors and connotations that further increase the suffering of individuals living with these conditions. For instance, the military language that we use around cancer sufferers can be deeply challenging. Often people living with cancer are encouraged to do battle with cancer, to fight it, to perceive it as the invading enemy within that needs to be eradicated so that they can be freed to live. Living with cancer is war. But what if I want to befriend my cancer and live with it peaceably? Likewise, AIDS, which is nothing more (and nothing less) than a virus, attracts to it metaphors and assumptions such as deviance, addiction, homosexuality, and promiscuity that have nothing to do with its biological root. Bodily illness is transmuted into social stigmata which lead to the marginalization and alienation of sufferers for whom the enforced cultural metaphors cause distress and misidentification.

Those living with addiction experience all the difficulties that Sontag highlights. But there is also another dimension to their social suffering. Alongside these linguistic and cultural issues is an ontologizing of addiction wherein the person is assumed not just to suffer from an addiction, but actually to become his or her addiction. If one has measles, one is not normally referred to as a measle. But if one has an addiction, one is often given a new name: addict. The term addict is rich in metaphor and stigma. The ascription of the term baptizes people into a social role wherein their real names are overpowered by their collective social name. But what exactly is an addict? When we talk about addicts, we are not talking about people who are somehow other than ourselves in the way that New Yorkers may be different or other than Scotsmen! Addicts are not a people group, and addiction is not a cultural marker. People with addictions are people in pain. Many of them need and desire the love of Jesus, and their healing requires them to learn how to love themselves more fully in order that they can recognize the love of God and come to love and be loved by their neighbors. One of the important things that emerges from this book is the reminder that addicts have names and that these names matter. Addictions are complicated.

Sonia Waters has gifted us in Addiction and Pastoral Care with a fascinating and important book that takes very seriously the multifaceted nature of addictions and the centrality of theology as a way of understanding and responding to this profound human experience. Moving us through a variety of fields from neurology to systematic theology, she takes us on a wonderful interdisciplinary expedition that will undoubtedly change the ways in which many of us understand and respond to people living with addictions. Readers of this volume will not only find some rigorous, fresh, and deep perspectives on addiction, they will also learn the kinds of theological and pastoral responses needed to respond to the complexities of addiction and to help guide people back toward their one true desire: Jesus. Much has been written on addiction within the pastoral literature, but in terms of its deep theological emphasis and breadth of knowledge and wisdom, this book offers something new. Readers with an interest in addiction and addiction studies will not be disappointed by what they encounter here.

JOHN SWINTON

Aberdeen University

Acknowledgments

In the pages that follow, I owe the greatest debt to the drug addicts and alcoholics—both active and in recovery—who have shared their stories and taught me so much about faith. I have also inflicted the progression of my ideas upon my students at Princeton Theological Seminary over the past four years, and they have blessed me with their intelligence, creativity, and patience. I am greatly indebted to the Rev. Stephen Faller, chaplain supervisor at Capital Health, who supervised my chaplaincy at a local rehab. Rev. Matthew Rhodes, chaplain supervisor at Princeton-Penn Health, also read and commented on the counseling skills in this work. Chaplain Rhodes and Rev. Mary-Jane Inman have let me try out various versions of these ideas on their chaplain interns at both Princeton Health and at Trenton Psychiatric Hospital. Rev. Jan Ammon, Princeton Seminary’s Minister of the Chapel, read through the whole manuscript and added much editorial and pastoral input. These ministers, whose vocations bring them daily to the center of so much suffering, remain an inspiration to me.

Professors Bonnie Miller-McLemore, Deborah Hunsinger, and Dale Allison offered crucial feedback at the beginning of this project and championed me in its pursuit. I cannot thank them enough for offering their time and encouragement to the formation of this book. Robert Dykstra also read an early version of the Gerasene chapter and has been a supportive mentor throughout my time at Princeton Seminary. Clifton Black kindly offered me mountains to read on the Gospel of Mark. My pastoral theologian colleagues from the New Directions in Pastoral Theology writing conference also patiently suffered through an earlier version of my thinking on addiction and the Gerasene demoniac. They have inspired my writing and encouraged me in this pursuit.

My partner, Rev. John Mennell, also read and critiqued several chapters and survived me as I completed the writing process. Without his influence, nothing would be linear. Former students Jennifer Herold and Mads Benishek edited and critiqued earlier versions of this manuscript, and Mads used his prodigious organizational talents to be the primary copyeditor for my manuscript. Finally, special thanks to my spiritual mentor Fran JFG,¹ who, when I asked what would happen if she went back to using, said, I’d lose everything. But most important, I’d lose my soul. I couldn’t have said it better myself.

Introduction

When I say the words heroin addict, what picture do you get in your mind? What people are engaged in this behavior? What do they look like, and where are they? What is wrong with them? What can they do to solve the problem? How does that solution actually unfold? Now, try the word alcoholic—or what about crack addict or marijuana addict? What picture do you get in your mind? What people are engaged in those behaviors? What do they look like, and where do they come from? What is wrong with them? What can they do to solve that problem? How does that solution unfold? Now, add another question: What part does the pastoral caregiver play in that problem, or in the unfolding of its solution?

I ask my students these questions on the first day of our class on addictions. I tell them not to give me their Christianly view—the one that they think they are supposed to give me. Instead, I want the first thing that comes to their minds: what they grew up thinking about addicts, what they heard in school, at home, and in the media. I ask for their unfiltered thoughts about why or how people become addicted and why or how they recover. In a class of about fifty students, I can get dozens of different perspectives. Together we write on a large whiteboard themes that are personal, social, and theological. We list contrasting debates between addiction as a habit, a brain disease, or a psychological problem. We see how our thoughts about addiction intersect with stigmas about poverty and homelessness, assumptions about race and gender, and political rhetoric from the war on drugs. We see them inevitably tied to questions of sin, will power, and weakness of character. We admit to stereotypes about delinquency and failure: addicts as the dregs of society. We point to personal consequences, such as loss of family, home, and sometimes even life.

Substance addictions are fascinating because they are positioned—or perhaps, more accurately, constructed—at the converging point of so many other discourses. Everyone, from neuroscientists to social workers, from public-health advocates to the police force, has something to say about the causes and cures of addiction. There is an official diagnosis of Substance Use Disorder in the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-V), suggesting that these addictions are mental health conditions.¹ But, unlike most other mental health conditions, addictions are openly treated as a crime. They are expressions of individual suffering and broken family systems but they are also the province of politicians and presidents, who promise to keep the streets safe for our youth. They fuel the inordinate incarceration of African Americans and Hispanics in the war on drugs. They are attached to images of homelessness, prostitution, and degeneracy. They evoke our deepest assumptions about how human beings express agency and responsibility in the world.

When students discuss the role of the pastoral caregiver in the problem’s solution, we need a whole new board to write their responses. We hear about the ministry of presence, the power of prayer, faith healing, planning an intervention, and offering exhortation. Some swear by Alcoholics Anonymous (AA) and others by Celebrate Recovery (CR). People share with others a host of homegrown ministries that originate from their local churches. They tell stories about loved ones who were healed and loved ones who never got clean. They talk about fears of not being good enough as caregivers. Sometimes they admit that they are not sure what to do with addicts. After all, they can be confusing people to be around: sometimes they are pitiful and emotional, and sometimes proud and untouchable. They say one thing and then they do another. At some level they seem detached from the chronic behaviors that are taking over their lives. Most of us have seen friends and families, parents and parishioners disappear into this senseless, repetitive excess. We invest in their recovery, we try to help, and then they fail us. At least, that is what it can feel like, if we are honest.

Addictions are a pastoral challenge because we don’t really know how an addict heals and we don’t know how to relate to an addict who is in that process of healing. If addictions are so multivalent, then easy solutions evade us. How we define a problem affects how we view the solution, and these differing definitions across the board lead to very different solutions: from medicine to conversion, from exorcism to social activism, from doing everything to doing nothing. By the end of a very full whiteboard, it is also clear that both our first definitions and our later solutions produce a certain way of seeing the person before us—as a criminal, a victim, a moral agent, or a medical patient, just to name a few.

The process of healing from addictions is complicated, and it evokes complicated feelings within us as pastoral caregivers. But I usually try to make it even more complicated on our first day of class, just for fun. At some point in that class conversation, I rather unfairly lob the question of theology into the middle of the room. Right now, what is your theology of addiction? How do you see addiction through the lens of your faith? By now, the students are annoyed. Many students believe that addiction is a disease, and so they are not sure what to say about it theologically. Maybe they’ve just been trained to make a bifurcation between science and faith. Or maybe they assume that a theology of addiction necessitates a theology of sin. If this is a medical problem, it seems outside of the purview of theology. Others don’t want to lose some notion of sin: they believe that people should be responsible for their actions. After all, they assure me, sin doesn’t mean that addicts are bad people, because we all sin. The only problem is that, if we all sin, then it is not a particular theology of addiction.

If pressed to say something Christian about addictions, students on both sides of the issue—addiction as a sin or addiction as a disease—usually find themselves talking about the age-old themes related to free-will sin. Addiction is idolatry, desire gone awry, gluttony, the pursuit of pleasure, a turning away from God. These themes don’t quite fit the idea that addiction is a disease, but people who hold to the disease model don’t know what else to say about it, spiritually speaking. Christians think about the spiritual life in terms of spatial metaphors: we draw near, turn away, become lost, get separated, or distance ourselves from God through our actions. These are also related to sin, since we are responsible for the direction in which we turn. But a focus on the direction of the individual spiritual life does not take into account the many descriptions of addiction that we wrote on our first board: the broad multivalence of its personal and social causes, its myths and stigmas.

If you were to see the state of my whiteboard at the end of that first class, or the annoyance of my students, you might agree that addictions are confusing. They suffer from a lack of conceptual clarity. We will review the diagnostic criteria for substance use disorder in chapter 1, but even this list of symptoms is based on subjective experiences (personal consequences, time spent in the behavior) that are not easily measured. How many consequences do you need to have before you become an addict? Do you have to use drugs or alcohol every day? Can you be successful in your job and still be an addict? Are you doomed to have a lifelong disease, or is it merely a life-cycle phase? Frankly, addiction is a constructed category: someone noticed these particular behaviors, argued about them with their fellow researchers, and organized them into the Diagnostic and Statistical Manual-V. This allows certain people to get an official diagnostic label of substance-use disorder and thus gain insurance or health-care benefits. While medical and mental-health institutions want to standardize such diagnoses for addictions, ultimately only the individual can know whether or not she has a problem with substances. Combine the personal experience of substance abuse with all the other social and political intersections on the board, and two people could be talking about two very different things when they have a conversation about addiction.

Addiction across the Board

Pastoral theologians like to start with lived experience. We try to build a picture of the human situation—particularly situations of suffering— in order to more fruitfully engage the resources of the faith in understanding and addressing that situation. This is not a one-way street; the human situation also has its own theological weight. Lived experience and its broader context teach us about ultimate concerns, about the God-human relationship, and they also correct or critique what is missing in our theologies through their cries for justice.² Finally, practices of community and care are a part of our lived experience, which is why the question of how one heals, or how the pastoral caregiver or community is involved in that healing, is a crucial part of the equation. These practices hold implicit theologies and value systems that need to be brought to the surface for further reflection.³ For instance, practices of addiction care—from DSM-V diagnoses to drug court to Celebrate Recovery—assume very different types of people and describe different problems. Certain understandings of humanity and its problems are enabled by these practices of care, and other expressions are limited. So pastoral theologians construct a particular version of a sick person from the multiple theories available.

As I develop a picture of addictions in this book, I try to honor the lived experience across our classroom whiteboard, scattered as it is with its personal, social, political, and spiritual issues. To sustain some order in this approach, I move from the individual brain to its attachment relationships, and then out into the social world. The individual and his or her inner life is a part of the picture of addiction and has long been a source of pastoral theological reflection as a living human document.⁴ This means that individual experience offers its own source of knowledge, like a written text that enters into conversation with the spiritual and theological texts of our faith. But my whiteboard looks more like what Bonnie Miller-McLemore calls a living human web.⁵ Each individual is located in a web of constructed meaning. Problems may feel like individual issues and may cause individual suffering, but a person’s subjectivity—how she experiences or interprets the experience of self and other—is formed by how she is situated within the structures and ideologies of her communities and contexts. My aim is to take an issue that is often highly individualized and trace its webbed connections to the relational and social contexts that make one vulnerable to addiction, create its stigma, and complicate its recovery. This broader picture will then inform my Christian reflection on aspects of addiction and its care.

The living human web also expands pastoral theology into responses that address the socioeconomic and political suffering of the marginalized. We can pay attention, not just to the person, but to the systems of oppression within which they are situated. African American pastoral theologians such as Archie Smith, Edward Wimberly, and Lee Butler have long advocated for a pastoral theology informed by African American history, culture, and the experience of historic and institutional oppression.⁶ Ryan LaMothe also broadens the scope of pastoral theology into political theology, including the lived experience of global market capitalism.⁷ Racial and socioeconomic oppression play a large role in the story of addiction, especially through the war on drugs and its inordinate policing and incarceration of African Americans, Hispanics, and poor whites.

So while I will be offering individual listening skills in chapters 6 and 7, I am building a picture that considers our broader work as pastoral caregivers, including how we use Christian practices, form caring communities, and engage in political advocacy. The image of the web suggests that we are not atomized individuals closed in upon ourselves. Instead, we are multiply connected to personal, social, and political experiences of both vulnerability and resilience. This can help us understand the individual better but it can also expand our caring work to the social, political, and economic suffering that might complicate addiction. Issues of racism and homophobia, poverty, and the economic insecurity embedded in the shifts of global-market capitalism are all a part of this web. Addiction is not a cause of social decay; rather, it is a symptom of the suffering that grows when we ignore God’s call to justice and care for the vulnerable.

As I expand outward from the personal to the social, I describe addiction as an emergent condition arising from how multiple vulnerabilities organize themselves around the repeated behavior of using. It is not just one cause that creates an addiction, but a dynamic tangle of vulnerabilities that catch the individual in the net of addictive behavior and can accelerate the progression of the condition as it grows. I focus on the progress of addiction because I think that it adds a dimension to the pastoral care of addictions that has been undertheorized in Christian writing. There are manuals that help pastors identify the end-stage condition of substance use disorder, there are personal spiritual reflections that connect addiction to the inner life, and there is a recounting of the debate between those who see addiction as disease and those who see it as a moral choice. But we have not really considered that the very emergence and progress of addictions have theological weight: how self-regulatory, ritual behaviors attempt to manage what I call a legion of personal, relational, and social sources of suffering. Addictions progressively eat away at the soul, affecting the sufferer’s hold on reality, his moral decision-making, his sense of self in relationship to God, and his sense of a right relationship with the world.

As I build this more webbed picture of addictions, the themes of multiplicity, progression, identity, and loss will recur throughout these pages. They culminate in a detailed discussion of the Gospel of Mark’s Gerasene demoniac in chapter 5, which I use as a metaphor for the complex interrelationship of personal experience and social suffering in addiction. These dynamics teach us something about our own more complicated role in caring for addicts. From the outside, it may seem like addiction is a single self-harming action, where it is obvious that giving up the addiction means claiming a happier, healthier life. This is not so obvious to an addict. From the inside, many addicts experience a threat to their behaviors as a threat to the way that they have organized their understanding of the self and its relationships. Death is involved in addictions, from the original losses and sufferings that compelled their engagement to the identity that must die in order for addicts to recover from their hold. Thus to lose the addiction is a process of grief. This truth will evoke some themes that travel across these pages: that we do not easily get over such a loss; that recovery is a process of changing identity; that woundedness and death are the slow, ambivalent sources of new life.

I know that the classroom whiteboard could be organized differently. If you do not hear your story within these pages, it doesn’t mean that your experience of addiction is less real for you. Not every person will claim that relational and social losses were a part of their addictive behaviors. Not everyone thinks that addictions cause permanent changes to the brain. Addiction is a highly contested concept. In the end, I am not able to tell you what addiction ultimately really is. Instead, I hope to offer a compelling version of how we might imagine it to be. I believe that this version is a faithful attempt to capture addiction’s complexity and also to encourage our compassion. I am trying to embrace pastoral theologian Elaine Graham’s criterion of usable but not innocent for my choices toward interpretation. Her pragmatic perspective maintains that we recognize the tentative and provisional nature of our claims to ‘truth,’ yet we still maintain a commitment to ‘usable knowledge’ as a working and strategic hypothesis.⁸ I hope that this book represents a strategic hypothesis for addiction that will help pastoral caregivers more broadly to serve the individuals and communities that come to us for care.

Addiction Organized

In chapter 1, I provide some foundations that will organize my thoughts on addiction throughout this book. First, addiction is relational; second, it is motivated by the problem of pain, not the desire for pleasure; finally, it is an emergent condition that progressively takes over the will. Addictions do not arise from one cause but from how multiple personal, relational, and social vulnerabilities organize around substance use, as we attempt to regulate negative affect and manage stress. I argue that addictions are one of a class of spiritual bondage that I call a soul-sickness. They are signs of the soul in distress. Over time, addictions injure the soul, progressively estranging the individual from self, other, and God. I introduce the image of the Gerasene demoniac’s legion to symbolize the existential and spiritual suffering of this condition, and I will continue to use the term legion to represent the multiplicity of addiction throughout this work. Like the Gerasene’s legion, addictions emerge from many forces that have organized into one voice. They combine and overtake the self in ways that are self-destructive and socially stigmatizing, similar to how we might imagine the Gerasene’s demon possession.

In chapter 2, I explore how addiction progresses through our brain functioning. Neurobiological perspectives suggest that addictions create a chronic state of stress and negative affect in the user, leading to a kind of spiritual bondage where the individual attempts to escape the stress of using with yet more substance use. I review the dynamics of neurotransmission, tolerance, withdrawal, and craving. I use a simplified image of instinctual and executive neighborhoods in the brain to talk about what researchers call hypofrontality. This is the diminished connection between the part of our brain that initially takes in information and codes automatic responses and the part of our brain that processes information deliberately. I review changes to the reward system in the brain, which is implicated in both substance abuse and behavioral addictions. The neurobiology of addiction is important for care because I so often hear people confuse addictions with other strong attachments or questionable temptations. I can’t count the number of times people have said to me, But aren’t we all addicted to something? No, we’re not. If the growing research in neurobiology is correct, the brain in a state of addiction is not the same as the brain that is not addicted.

Self-regulation leads me to my third premise behind a soul-sickness: addictive behaviors