the strict daily discipline of ministry routines and the chaos of family life that the routines were supposed to guard against seemed familiar. Bubsie’s death was followed by James’ death from cocaine-related kidney failure. Billy drifted in and out of unemployment, but after my grandfather died, he joined Alcoholics Anonymous and my grandmother’s church. He got credentialed and eventually taught English in the same middle school in which my grandmother had worked.
My family’s frustrated aspiration, tenuous class background, and ethnic marginality guided my ethnographic curiosities. Although I had to check my tendency to project my family’s concerns onto my island Puerto Rican informants, identifying with my informants might have enhanced my patience regarding our differences, as well as my interest in their self-image as members of families and communities rather than as deviants.2 I noticed that my practice of inviting ex-cocaine and heroin users to my home was not matched my professional colleagues. As a public health researcher in Puerto Rico asked me in disbelief, “You mean, you let your daughter meet the addicts?”
Like most biomedical practitioners in Puerto Rico and the United States, I was taught the Biopsychosocial Model (Engel 1977) in medical school. In contrast to evangelists—who relate all forms of suffering to the state of one’s relationship with God—the Biopsychosocial Model defines three discrete levels of influence on the health of an organism: biological, psychological, and social. The clinical diagnosis of substance dependence links physiological symptoms (such as tolerance and withdrawal symptoms) and psychological symptoms (such as the compulsion to use drugs) with social symptoms (such as avoidance of important occupational or recreational activities due to substance use). George Engel intended to call attention to neglected social factors with his Biopsychosocial Model, but in practice physicians often consider biology to be primary: physiological changes effect psychological changes, which in turn influence social adaptation. For these physicians, biomedicine enhances social functioning by improving physical functioning; social problems are caused by physical infirmities.
Because ex-addicted evangelists think of volition not in terms of biological vulnerability but in terms of spiritual power, they reject the central criterion for the diagnosis of substance dependence as described in the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM): loss of control. The idea of loss of control, in the biomedical frame, implies that an individual no longer is able to choose whether to use substances in a logical manner—he is the victim of his pathophysiology, psychopathology, or genetic inheritance. Many addiction specialists believe that framing addiction as disease reduces stigma and helps patients to accept and treat their conditions (McLellan et al. 2000).
The diagnosis of substance dependence offered in the DSM is seamlessly biomedical. Making the diagnosis requires a clinician to check off three or more items from a list of seven symptoms that the patient reports having had in the previous twelve months (see Appendix I DSMIV-TR). But moving from diagnosis to treatment in a doctor’s office is not a straight path. Pharmacological treatments for narcotics dependence often yield suboptimal results and have side effects; and in the case of opioid maintenance for heroin dependence (such as the prescription drugs methadone and buprenorphine), they are so highly regulated that most physicians are not licensed to prescribe them (Greenfield 2005). Medical school and residency training in treating addiction is minimal. One study found that less than 1 percent of U.S. medical school curriculum hours are devoted to addictions (Miller et al. 2001), and only half of all U.S. residency programs offer any training in substance abuse intervention (Isaacson et al. 2000), despite the fact that substance abuse directly accounts for more than 10 percent of U.S. health expenditures (CASA 2009). As a result, many clinicians feel powerless when confronted with their most difficult patients: the addicted ones. Biomedical training does not provide clinicians with psychosocial tools; they resent their addicted patients as manipulators and, in turn, addicted patients suspect physicians’ malice (Merrill, Rhodes, Deyo et al. 2002).
This thinning of social and cultural understandings of patients is acute in psychiatry—the biomedical specialty charged with treating addiction. In its effort to standardize diagnosis and treatment through biological models, psychiatry largely has become biopsychiatry and the strength of its doctor-patient communication has atrophied. Academic psychiatrists—with notable exceptions (e.g., Kleinman 1988, Kleinman 2007, Galanter 2005, Lewis 2011, Fullilove 2013)—focus on the neuroscience of mental disease and remain silent on spirituality and social connection. Psychiatrists understand and diagnose patients on their own biomedical terms rather than the patients’ terms. Built on the authority of practitioners and the scientific expertise ensconced in pharmaceutical markets (Lakoff 2005, Martin 2006, Rose 2003, Healy 2006) that delimit pharmaceutical selves (Jenkins 2010, Martin 2006, Rose 2003, contemporary psychiatry does not recognize that many patients have their own theories of disorder and treatment. Neither does it recognize systemic ethnic and racial bias in health care (Roberts 2011, Metzl 2010), nor the criminalization of addiction through disproportionate drug-law enforcement in non-White neighborhoods (Alexander 2012). The outcome is that a great number of addicted people arrive at clinics desperate for help, but leave facilities alienated from their doctors.
Although biopsychiatry promises practitioners universal truths and power, its reductionism costs them; I repeatedly have seen that the patients who the hospital staff fear the most are the working-class Latino and black addicts.
This book represents my efforts to understand addiction from a vantage point as radically outside of biomedicine as I can imagine. Yet, in the end, I found commonalities between the biomedical and evangelical understandings of addiction, and recognized overlap in the practices of addicted people who move from biomedical to evangelical institutions and back again. Addiction ministries are autonomous from the clinic, but also are a reaction to the clinic. At times they are combined with biomedicine. Well-meaning people on both sides of the issue benefit from a nuanced understanding of the other position, and of the elements common to biomedicine and evangelism that ultimately move people beyond addiction. After all, addiction often leads to severe distress during which the meanings that people attach to their acts—and the openings that they find for hope and change—are matters of life or death.
Acknowledgments
This book already has had a long life. Its early germination and cultivation began with its first official readers, Linda-Anne Rebhun, Kate Dudley, Philippe Bourgois, and the late Patricia Pessar, along with Tony George who helped me to cross-fertilize my ethnography with clinical investigations, even inside of the ministries. My first writing group partners had a profound early influence on my thinking: Ping-Ann Addo, Lyneise Williams, Judith Casselberry, Jennifer Tilton, and Gilbert Mireles.
I thank Roy Thomas, Robert and Mindy Fullilove, Robert Levine, Woody Lee, Kai Erikson, Nancy Angoff, Curtis Patton, Nora Groce, and my brother—Ben Hansen—for the inspiration and enduring support during my field research and beyond. My brother and sister—Martin Damhaug and Sara Brinch—and my stepmother, Kari Damhaug, also inspired me.
The financial and moral support in those early years of the NIH Medical Scientist Training Program, the Social Science Research Council, Yale’s Williams Fund, John Perry Miller Fund, Council on Latin American Studies, and also my husband Mark Turner (who contributed multiple insightful readings of fieldnotes and drafts), my mother Jacquelyne Faye Jackson; my grandparents, John and Mildred Jackson, and Conrad and Eva Hansen (posthumously); my parents-in-law, Joyce and Al Dixon; my grandparents-in-law, Violet and Lewis Jackson and Millie Brown; and my father, Arne Bjerring Hansen, made this project possible.
I thank those who generously opened the doors to my study of addiction treatment, Christian life, and mental health policy in Puerto Rico, including those informants who I cannot thank by name, as well as Margarita Alegria, Carmen Albizu, Salvador Santiago, Irene Melendez, Ann Finlinson, Hector Colon, Tomas Matos, Rafaela Robles, Maria del Mar Garcia, Gisela Negron, Midred Vera, Nemesio Moreno, Victor Vargas, and many others.
Jessica Rodriguez, Raul Medina, and Maria Teresa Botello gave me tremendous emotional and practical support during
