Understanding Shame

There continues to be an ongoing gap between how addiction gets treated and how it actually works.

Knowledge and behaviour are handled by different systems. Insight lives largely in the prefrontal cortex — the part of the brain that plans, weighs consequences, and holds “I know this is bad for me.” But addiction increasingly reshapes subcortical circuits involved in craving, habit, and stress reactivity. Under cue exposure or stress, those older circuits can override the newer, knowledge-holding ones. This is why someone can recite their relapse triggers perfectly in a therapist’s office or recount pages of 12-step literature from memory and still act against that knowledge the moment they’re actually standing in the triggering situation.

Wiers and colleagues’ work on “dual process” models of addiction — explicit cognition versus automatic, implicit approach biases — captures this well. Cognitive bias modification research grew directly out of the finding that explicit knowledge doesn’t touch these automatic processes.

The transition from goal-directed use to habit. Everitt and Robbins’ work describes how repeated substance use shifts control from goal-directed brain circuits (which respond to consequences and knowledge) to habitual, and eventually compulsive, circuits centred in the dorsal striatum. Compulsive behaviour is, by definition, less responsive to knowing better. Decades of use can entrench this shift very deeply.

For example:

Early: goal-directed. Bad day → “I want to relax” → decide to drink. The action is chosen and tied to an expected outcome. If consequences got bad enough, the person could still stop — this runs through prefrontal cortex and ventral striatum.

Middle: habit. After years of stress → drink → relief, the sequence no longer needs a decision. Walking in the door at 6pm triggers pouring a drink before any conscious “do I want this?” moment happens. The cue now drives the action directly. Control has shifted to dorsolateral striatum — same circuitry as driving a familiar route on autopilot.

Late: Compulsive. In Everitt and Robbins’ animal studies, drug-seeking gets paired with a mild shock. Most animals stop once punished. But a subset — roughly a third, matching the rate of severe addiction in humans — keeps seeking the drug even though it now reliably delivers a shock. That’s the model for compulsion: behaviour persisting despite known, immediate harm.

The human version: Someone with DUI’s, lost relationships, health scares — every piece of proof the behaviour is destructive — still relapses. Not from lack of knowledge; they’ve lived the consequences repeatedly. The circuitry driving the behaviour at this stage doesn’t consult the consequence-tracking system the way it did early on.

This is also why pure education or insight-oriented therapy often under-performs at this stage — it’s arguing with a system that isn’t listening. Interventions that interrupt the cue-response link itself (contingency management, environmental restructuring, craving-blunting medication, removing triggers) tend to have more traction, because they target the habit/compulsion circuit rather than trying to out-inform it.

Koob and Volkow’s allostasis model. Their research reframes chronic addiction as a shift from positive reinforcement (seeking a high) to negative reinforcement (avoiding a increasingly severe dysphoric, anxious, irritable state without the substance). Long-term users aren’t chasing a reward anymore — they’re fleeing a state. That flight response is fast, automatic, and largely indifferent to intellectual understanding.

Unresolved comorbidity. A large fraction of people with treatment-resistant, decades-long relapse patterns have under-treated trauma, complex PTSD, personality disorders, or conditions like ADHD sitting underneath the substance use. If the underlying driver isn’t directly addressed, coping skills training treats the symptom while the engine keeps running. This is a common finding in dual-diagnosis literature — outcomes are much worse when co-occurring conditions go unaddressed even amid extensive substance-focused treatment.

Recovery capital, not just recovery knowledge. William White’s work on recovery capital argues sustained recovery depends on social, financial, physical, and community resources — stable housing, relationships, purpose, employment — not just internal coping skills. Someone can have excellent DBT (Dialectical Behaviour Therapy) skills and still relapse repeatedly if their environment, relationships, or life structure haven’t meaningfully changed.

Relapse as expected, not exceptional. Prochaska and DiClemente’s stages-of-change model treats relapse as a normal part of the cycle, not a failure of knowledge. But when relapse repeats over decades despite intensive treatment, researchers increasingly look at severity markers — poly-substance use, genetic loading, age of onset, impulsivity and risk-taking — that predict a harder course regardless of how much psychoeducation someone has absorbed.

The consistent variable across all of this: Insight is necessary but nowhere near sufficient. Addiction at that level of chronicity behaves more like a deeply conditioned neurobiological and habitual process than an information deficit. That’s also part of why chronic relapse is increasingly framed like a chronic illness — closer to diabetes or hypertension in its relapsing-remitting course — rather than something insight alone should be expected to resolve.

Here’s what the literature and clinical guidelines point to for people who’ve cycled through standard treatment repeatedly without sustained success. I’ll organise by approach type.

Pharmacological — often underused

• For opioid use disorder, methadone and buprenorphine substantially outperform abstinence-only approaches in treatment-resistant populations — this is some of the strongest evidence in the entire addiction field, yet many long-term relapsers have never actually been offered maintenance medication, often due to program philosophy (abstinence-only 12-step programs) rather than clinical reasoning.
• For alcohol, naltrexone (blocks the reward), acamprosate (reduces post-acute withdrawal dysregulation), and disulfiram (aversive) are under-prescribed. Naltrexone specifically blunts the reward signal that drives compulsive use — targeting the biology rather than relying on willpower.
• Emerging: psychedelic-assisted therapy (psilocybin, ketamine) is showing promise in trials for alcohol and other use disorders, though this is newer evidence and not yet standard of care everywhere.

Interrupting the cue-response cycle directly

• Contingency management — tangible rewards for verified abstinence — has some of the best effect sizes in the literature, particularly for stimulant use disorders where no strong pharmacological option exists. It works by directly competing with the habit circuit rather than arguing with it.
• Environmental restructuring — changing routes, routines, social circles, physically removing cues — matters more than intellectual insight at this stage, because the behaviour has become cue-triggered rather than decision-driven.

Treating what’s underneath

• Systematic assessment for under-treated trauma, complex PTSD, ADHD, and personality disorders. Trauma-focused therapies (EMDR, prolonged exposure, Seeking Safety) address the driver rather than just the symptom, and are often skipped in standard programs focused on the substance alone.
• Integrated dual-diagnosis treatment (treating psychiatric conditions and addiction concurrently, by the same team) outperforms sequential or parallel treatment where the person bounces between separate providers.

Building recovery capital, not just coping skills

• Housing First and supported employment models — stabilising the environment before or alongside treatment — show better outcomes than clinical treatment alone in chronic, treatment-resistant cases. William White’s recovery capital framework: outcomes track with social support, stable housing, purpose, and community as much as with therapy itself.
• Recovery community centres and mutual-aid alternatives beyond 12-step (SMART Recovery, Refuge Recovery) matter for people whose repeated 12-step involvement hasn’t translated to sustained sobriety — fit between the person and the model isn’t universal.

Reframing the model of care itself

• Treating addiction like a chronic relapsing-remitting illness (the diabetes/hypertension model) rather than an acute, curable event changes what “treatment resistant” even means. Long-term, low-intensity, indefinite maintenance care (medication, periodic check-ins, ongoing peer support) shows better outcomes than repeated cycles of intensive short-term treatment followed by discharge.
• Harm reduction as a bridge or destination — not necessarily full abstinence — for people who haven’t achieved abstinence-based sobriety after years of trying. This reduces mortality and morbidity even when abstinence isn’t currently achievable, and can sometimes become a pathway toward it later.
• Multidimensional Family Therapy / systemic approaches — treating the family/relational system rather than the individual alone — show better outcomes for people whose relapse is tangled up in unchanged relational dynamics.

Purpose

This report summarises how clinical psychology and psychiatry generally understand people who believe that killing others is justified, necessary or required because of a religious or ideological cause. It uses plain language where possible and distinguishes extreme beliefs from mental illness.

Believe it or not – Key finding

A belief that killing people is justified by religion does not, by itself, mean that a person is mentally ill.

This is an important distinction. Contemporary psychiatric literature indicates that members of terrorist or extremist groups do not generally have higher rates of mental illness than the general population. Mental illness appears to be more common among some lone-actor extremists, but it still cannot be assumed to be the explanation for their behaviour.

In other words, someone can be psychologically capable of understanding what they are doing, planning it deliberately and believing that it is morally right, while not suffering from a psychiatric disorder.

1. Extreme religious belief is not necessarily psychosis

Psychosis involves a significant loss of contact with reality, such as hallucinations or fixed false beliefs that are not reasonably explained by the person’s cultural or religious background.

For example:

• Extreme ideology: “My religion teaches that these people are enemies of God, so killing them is justified.”
• Possible psychosis: “God is personally speaking to me through my television and has instructed me to kill my neighbour because he is secretly a demon.”

The first statement may represent an extreme ideological or religious belief. The second could indicate a psychiatric disorder, particularly if it occurs alongside other symptoms of psychosis.

A psychiatrist would therefore ask much more than “Does this person have strange beliefs?” They would examine whether the person has lost the ability to distinguish their beliefs from reality and whether there are other symptoms of mental illness. Distinguishing extremist beliefs from symptoms of mental disorder is recognised as an important difficulty in psychiatric assessment.

2. How can an otherwise ordinary person come to accept killing?

Psychology provides several explanations that do not require mental illness.

One is moral disengagement. This is where a person changes the way they think about an action so that something normally considered wrong becomes acceptable.

An ordinary example would be a soldier being trained to think of an enemy as a threat rather than as an individual person with a family and a life.

In extremist thinking, this can become much more extreme:

“They are not innocent people. They are enemies of God.”

Once someone has been placed into an “enemy” category, killing them can become psychologically easier to justify.

3. The importance of an “us versus them” mentality

Extremist movements often create a very strong distinction between “us” and “them”.

The person may increasingly see:

• their own group as good, pure or righteous;
• outsiders as corrupt, dangerous or evil;
• disagreement as evidence of hostility; and
• violence as self-defence or moral duty.

This is something ordinary people can recognise in less extreme forms.

For example, football rivalry can involve “us versus them”, but most people retain the understanding that the opposing team’s supporters are still ordinary human beings.

Extremism can take the same psychological distinction to an entirely different level, where the opposing group is no longer regarded as deserving the same moral consideration.

4. Religion can provide a powerful justification

Religious belief can become particularly powerful when something is regarded as a sacred or absolute value.

If a person believes:

“This is God’s command”,

then ordinary moral reasoning can change.

Instead of asking:

“Is killing this person morally acceptable?”

the person may ask:

“How could I disobey God?”

This can produce a situation where the individual genuinely believes they are doing something morally good, despite the fact that an outside observer sees the behaviour as horrific.

That does not make the behaviour acceptable, nor does it make the belief reasonable. It helps explain how the person can psychologically reconcile their actions with their own sense of morality.

5. Believing something and acting on it are different

Clinical assessment is particularly interested in the difference between extreme beliefs and a pathway towards violence.

A person might say:

“I believe people who oppose my religion are evil.”

That is concerning, but it is different from:

“I have decided to kill someone.”

And that is different again from:

“I have chosen a target, obtained the means to do it and have started preparing.”

Psychiatric risk assessment therefore looks for behavioural evidence of movement towards violence, rather than simply diagnosing someone based on their political or religious beliefs. Contemporary forensic psychiatry specifically emphasises identifying warning behaviours and distinguishing extremist beliefs from an actual pathway towards violence.

6. Mental illness can nevertheless be involved

Some people who commit extremist violence do have mental disorders.

For example, a person could have:

• schizophrenia or another psychotic disorder;
• severe depression;
• a personality disorder;
• substance-use problems;
• significant paranoia;
• or another condition affecting their judgement or behaviour.

However, clinicians should not automatically assume that the mental illness caused the extremism.

The relationship may instead look something like:

Personal grievance + extremist ideology + social reinforcement + psychological vulnerabilities + opportunity + willingness to use violence

rather than simply:

mental illness → terrorism.

Research specifically cautions against looking for a single cause or single psychological profile for radicalisation.

7. The most important clinical distinction

From a clinical perspective, there is a major difference between:

“This person believes something that I consider bizarre, frightening or morally repugnant.”

and

“This person has a psychiatric disorder that is causing them to lose contact with reality.”

Those are not the same thing.

A person can be completely sincere, highly intelligent, psychologically organised and fully aware of their actions, while holding an extraordinarily dangerous ideology.

That is one reason psychiatry does not regard terrorism or religious extremism as a diagnosis in itself.

Conclusion

Clinical psychology and psychiatry would generally view religiously motivated killing as a complex interaction between ideology, psychology, social influences and individual circumstances, rather than automatically as evidence of insanity.

The crucial question is not simply:

“Are their beliefs extreme?”

It is:

“What is driving those beliefs, how firmly are they held, is the person able to distinguish belief from reality, and have they moved from believing violence is justified to actually intending, preparing or attempting to carry it out?”

That distinction is important because a mentally ill person is not necessarily dangerous, and a person who is not mentally ill can nevertheless become extremely dangerous. Contemporary psychiatric literature explicitly warns against confusing mental disorder with extremist ideology and instead emphasises assessing the person’s actual pathway towards violence.

I would infer that you may be depleted in some area of your life. Generally, when I am having any of these experiences I can recognise that my basic needs, and possibly even transformative, needs are not met. My basic needs are food and water, adequate sleep, shelter and safety, social connection (belonging), and esteem needs (e.g., self-respect, self-worth, self-competence, mastery and achievement, integrity, sense of freedom and independence etc.). Perhaps only when all my deficiency needs are met, and I’m experiencing dissatisfaction with my growth needs, do I feel Restless, Irritable, and Discontent in this area of my life – however I assume some would argue that if I am feeling that way when attending to my growth needs, then I may have slipped back to Esteem Needs. You can look up Maslow’s Hierarchy of Needs for a visual representation if you like, using a search engine. Below is a GIF that I created to educate people on how we can buffer ourselves to vulnerabilities. It’s very telling to go into the body when we haven’t eat for a while, may be we’re running on caffeine, and you can feel the restlessness in the body. We have to fuel up when we’re hungry to buffer ourselves from becoming irritable and restless. If you’re feeling discontent with life, I would suggest a social activity, play time with friends, working on a project of some kind, or getting involved in your community.