gender and domesticity two years after my original field research. Through these individuals we see that Pentecostalism—premised on the ultimate authority of personal, mystical experience—often is billed as an individualist replacement for extended family networks of the poor. In practice, however, Pentecostalism builds on these networks and its success is contingent on them. Together these chapters flesh out the promise and the limitations of Pentecostal strategies to rework gender and family as social technologies of transformation.
CHRONICITY AND CHANGE
Is addiction a disease?
Eight years after my research in Puerto Rican street ministries, in my last month of an addiction psychiatry fellowship, I was assigned to the inpatient addictions unit of a large New York City hospital. The staff hastily passed patients’ rooms, hovering two feet from the door. Thick glass insulated the nursing station from patients who frantically knocked on its window to ask for phone calls—and for sedatives.
I made a point of greeting a Puerto Rican woman who the medical assistants warned me was “unpredictable.” She was admitted the night before, had been sleeping all morning, but sat upright when I approached. Her hospital gown slipped off of her shoulder, showing skin as grey as the roots of her brassy hair. “Where is my methadone?!” she barked. Explaining that we hadn’t started morning medications, I caught her fist squarely in my chest, all she could muster from her withered arm. I froze, leaning toward her bed. Within seconds someone pulled me into the hall as medical assistants and nurses formed a circle around her. The crisis team appeared: African American former high school football stars hired from local housing projects. They told her she was going to get some rest, and held her to the bed as she screamed for methadone. A Filipino nurse injected her with tranquilizers.
Six hours later, nodding from the medications, she called me in to apologize. “I’m sorry about that—it’s just, you know, I need my methadone.”
My supervisor scolded me for walking so far into the patient’s room. “You see how the drug hijacks their brains.” In our classroom he had stood at the chalkboard, drawing dopamine receptors in the nucleus accumbens of the brain and its pathways to the forebrain, the seat of conscious decision making. He cited experiments derived from the behaviorist conditioning models of B. F. Skinner, describing the pleasurable reward of cocaine and heroin as “focusing us exclusively on pursuit of the drug, and making future oriented, cost-benefit analysis impossible.” It was an updated rendition of “Diseases of the Will” that historian Marianna Valverde (1998) had traced to Victorian doctors trying to account for addiction as a condition that took away self-control. Self-control, Valverde pointed out, was the distinguishing trait of humanity (as opposed to animal life) according to Enlightenment philosophy.
Biomedicine blames not only the substances, as Victorian temperance campaigns had, but also blames the individual’s genetic predisposition to addiction, and blames irreversible damage to the brain from long-term drug use. For instance, biomedicine’s “opiate receptor depletion hypothesis” proposes that chronic opiate use leads neurons to stop producing opiate receptors, to dampen the effect of high levels of opiates on neurons. This change explains why tolerance develops—that is, as the brain stops producing opiate receptors, higher doses of opiates are needed to achieve the same experiences of pain relief and pleasure. According to this theory, taking high doses of opiates daily over a period of years makes this down-regulation of opiate receptors irreversible: the brain permanently requires higher doses of opiates to control pain and feel pleasure. The brain stops responding to its own physiological opiates, such as endorphins, and without doses of external opiates such people live in a state of pain and anhedonia, unable to experience everyday pleasures. This is the principal neurophysiological argument for opioid medication maintenance with methadone or buprenorphine as a clinical treatment for opiate addiction.
My supervisor’s biological hijacking lecture came on the heels of President George H. W. Bush’s “Decade of the Brain” (1990–2000), a decade during which Congress allocated billions of dollars to the National Institute of Drug Abuse (NIDA) for neuroscientific studies of addiction as a “chronic, relapsing brain disease.” Addiction researchers and clinicians believed that conceptualizing addiction as a disease would reduce the stigma of addiction by mainstreaming addiction treatment into general medicine. The end of the decade was marked by a lead article in the Journal of the American Medical Association—authored by four prominent addictions researchers and entitled, “Drug Dependence: A Chronic Medical Illness” (McLellan et al. 2000). It argued that the heritability, etiology, and treatment adherence of addicted patients were similar to those of patients with diabetes, hypertension, and asthma, and that addiction should be treated in the same way (with medications) and in the same settings (in general clinics) as chronic physical illnesses. Addictions researchers hoped it would leave sufferers less stigmatized and with the more realistic goal of stabilization (instead of cure), than would a moral-deficiency concept of addiction.
In Puerto Rico—a U.S. territory that receives federal public-health funding—this biomedical view of addiction was making inroads. Two major universities near the capital city of San Juan had substantial NIDA funding for addiction research. State-funded biomedical detoxification and rehabilitation programs were firmly established and were being privatized in Puerto Rico’s move toward managed care. Most of the converts I met in Puerto Rican street ministries had tried biomedical addiction treatment, and many of the patients that I interviewed in biomedical programs had been in street ministries; biomedical and Pentecostal approaches thus were intertwined in their biographies.
Yet, biomedicine and Pentecostalism are rooted in different views of the self. In biomedicine, the addicted self is damaged, cannot regulate itself, and therefore cannot protect itself from further harm. Its closed loop of physiology and behavior is captured in biomedicine’s foundational “self-medication hypothesis,” the hypothesis that addiction is a faulty attempt to treat oneself with substances that relieve symptoms, but that simultaneously weaken one’s capacity for self-care (Khantzian 1985). The idea of self-medication infuses biomedicine’s primary addiction-treatment strategies to this day—from maintenance medications such as methadone that relieve the discomfort of withdrawal and mimic the action of illegal opiates, to cognitive behavioral therapy and dialectical behavioral therapy, designed to give patients non-pharmacological strategies to regulate their own distressing emotions. A more recent addition to this framework is the “Stages of Change” theory (Prochaska and DeClemente 2005) that identifies deficits in patients’ recognition of, and motivation to change, self-harming behavior such as addictive behavior. This theory has been combined with communicative strategies called “Motivational Enhancement” and “Motivational Interviewing” (Miller and Rollnick 1992). Physicians and therapists use these strategies to change harmful behavior by providing verbal reinforcements that are tailored to the patient’s stage of change, and are adjusted as the patient’s motivation and insight progress. In this way, willpower is directly bolstered by the clinician. To interrupt the addictive loop of physiology and behavior, therefore, biomedicine provides either pharmaceutical or psychotherapeutic prosthesis that enables addicted people to care for themselves. Prosthesis is the technology of hope offered by biomedicine: the hope of targeting neuroreceptors and psychological deficits that drive addictive responses by using precise molecular and psychotherapeutic techniques—techniques that, by the scientific master-narrative of progress, continuously improve with new breakthroughs over time, restoring self-dominion. According to biomedicine, however, the addicted self always will require psychosomatic technologies to adapt to the world. This cultural model calls on our investment in the pastoral care of individuals as a requirement for their everyday survival.
For their part, street ministries turn the biomedical view on its head. In the ministries’ frame, rather than helping addicted people to adapt to their environment, they call on people to remake their environment with spiritual techniques. Rather than accepting their powerlessness against their biology as “drug dependent,” ministries attempt to tap the power of a spiritual movement. Rather than asserting that addiction is a disease of the individual, ministries see it as a sign
