Thursday, December 14, 2006

Overlooked Multiple Pathways to Recovery Due to Narrowly Tailored Substance Abuse Public Health – Su Joung Yoon

Limitations on Dichotomous View of Substance Abuse
Substance abuse public health messages and education campaigns can be an effective means for raising public awareness however it can inadvertently lead one to deny one’s addiction. Klingemann et. al interviewed substance abusers in which respondents pointed stigma and embarrassment as a big barrier to seeking help.(6) One respondent said ‘I don’t think anybody wants to be classified as an alcoholic or a drunk rummy. At least I didn’t. I was embarrassed, yes.’ Another respondent said ‘I don’t feel I’m an alcoholic period. I have a… I had a drinking problem but the word is terrible.’(6)

Consecutive surveys on images of the alcoholics in the mirror of the public opinion conducted in Switzerland in 1975, 1984 and 1992 demonstrated highly visible alcohol problems and a highly sensitized population. For example, 28% of the respondents in 1975 knew of a case of alcoholism; in 1984 the figure was 40% (9), and remained at a relatively high level in 1992. Many respondents associated alcohol problem as a disease, having the perception of severely dependent alcohol abusers suffering from a “chronically diseased and plagued with loss of control” medical condition.(7) Such perception leads severely dependent alcohol abusers to believe that people with substance use disorders cannot recover on their own and a failure to seek treatment for a substance abuse problem will have fatal consequences.(6)

For years, the addiction field placed an almost exclusive focus on these severely dependent individuals. Such emphasis has resulted in a myopic view of substance abuse problems that has characterized them as progressive, irreversible, and only resolved through treatment.(14) However, based on epidemiological surveys, Cahalan demonstrate that clinically defined ‘alcoholics’ constitute only a relatively small proportion of those whose drinking creates significant problems for themselves and society. In fact larger proportion was taken up by less chronic and severe drinkers.(2)

Substance abuse problems should be viewed as lying along a continuum ranging from no problems to mild problems to severe problems, rather than as dichotomous (i.e. alcoholic vs. not alcoholic; drug addict vs. not drug addict). Transitioning from dichotomous view of substance abuse to a continuum view has profound implications on how we treat substance abuse individuals.(6) One implication is that there would be multiple pathways to recovery just as there is a continuum of addiction phases. Self-change is a possible pathway, especially to less severely addicted individuals. Another implication is a portrayal of substance abuse individual as any other “normal” individual, a way to reduce stigmatization of substance abuse.

“Old” Intervention Strategies
Chin and Benne point out three basic strategies for public health interventions in addressing public health problems.(4) First is a rational-empirical strategy in which education is directed at trying to encourage people to change their behavior. Second is a normative-re-educative approach, referring to changing social norms to support healthier behaviors by persuading people to adopt a certain health behavior. Third is the power-coercive approach, referring to use of law to mandate certain behavior. Siegel states that typically the education and persuasion strategies are appropriate while in some cases a power-coercive approach may be necessary and appropriate.(11) Substance abuse public health messages and education campaigns in the past have applied all three strategies.

Over the years, public service announcements have been produced to educate the general public about the detrimental effects of substance abuse on health. Legislatures have passed laws and regulations to restrict the consumption of harmful substance. Education campaigns have been launched to curtail substance use as atypical social norm behavior and to seek treatment. Over the years the Substance Abuse and Mental Health Services Administration has produced and aired substance abuse public service announcements on TV and radio. In 2005, one TV service announcement clip called “Artist," featured a young artist who shared his struggle toward recovery. His journey began as he found himself isolated and alone, facing depression and a substance use disorder. Once he sought treatment, he was able to surround himself with people he loved and find recovery through his art. This public service announcement tried to emphasize the beauty and reconnection to society that is associated with recovery from substance use disorders by seeking treatment.(15)

However what happens if less severe substance abuse individual is not able relate to this artist? For potential changers who are in the pre-contemplations phase or weighing strategies for implementing change, the self assessment of the nature and the level of addiction as well as the public views on the addiction will highly impact one’s intervention actions. An abuser who see themselves in a less severe addiction phase may not want to identity oneself with those who are in “chronically diseased and plagued with loss of control” condition.(7) The abuser may even deny the addiction because his/her condition doesn’t seem to be that comparable to those who have a severe case of addiction. Such barriers will cause certain substance abuse individuals to deny their own addiction and disregard substance abuse public health messages since they feel they are not the intended targeted audience.

In the ‘Artist’ public service announcement, the general public will first see that the artist, as a substance abuser, was isolated and depressed. Possible attitude of a less severe abuser could be, “If I am not depressed and isolated then I can’t possibly be a substance abuser and why should I be classified in the same group, my addiction isn’t as severe.” This particular public service announcement, by engraving an image of a substance abuse individual as depressed and isolated, inadvertently placed more resistance for those who are in a less severe condition to seek treatment. Such resistance can be explained through the Labeling Theory defined by Howard Becker. The theory hypothesizes that the labels applied to individuals influence their behavior, particularly the application of negative or stigmatizing labels promote deviant behavior, becoming a self-fulfilling prophecy.(1) In alliance to this theory, no individual would want to be labeled as a “drug-addict.” If at all possible, the individual would choose not to be under the same classification and of course as a less severe substance user, denial is much easier than admitting to this stigmatized condition.

While the ‘Artist’ public service announcement may be effective to those who can admit to their addiction, isolated, and depressed, for those who cannot or will not classify themselves as a severe substance abuser, the message will only bring unnecessary resistance to recovery. The general public is already sensitized by similar substance abuse public health messages which labels substance abusers with certain stigmatized attributes. Thus a “new” approach to reframing substance abuse public health messages is necessary. In other words, these substance abuse individuals will have “pictures in their heads” drawn by past public health messages in regards to an addiction, thus any new information would only trigger these past pictures.(5) If stigmatization of substance abuse has already been engraved in the minds, then any new public health messages would only be assimilated into this stigmatized existing framework. Thus any new public health messages would only be working uphill to displace that frame. A “new” substance addiction intervention strategy framing is required and this time the message should not trigger the stigmatized images of a “typical” substance abuse individual.

“New” Intervention Strategy: Incorporating “Self-Change”
Current substance abuse public health messages seem to take the dichotomous approach to substance addiction – addicted or not addicted – and thus seem to target only the severely addicted users by referring them to seek help and treatment. The ‘Artist’ public service announcement exemplified this approach. However there are individuals who recover from addiction on their own without seeking outside treatment. These individuals are considered ‘self-changers’. Typically these untreated groups show less severe addiction histories.(12)

For many years the addiction field ignored ‘self-change’ as an area of study (13), and it was even considered a taboo topic by some.(3) The idea that someone with an addiction can overcome the problem without extensive professional help is met with disbelief by many health care professionals as well as the general public. As such, much of the substance abuse public message targeted the severe individuals. Thus, many in the addiction field are blind to the fact that there are multiple pathways to recovery. However in medical treatment methods, self change and management has been employed in recovery phase and promoting health. Pincus, Esther, DeWalt, and Callahan point out those patients with improved sense of control over their illness through self-management rather than knowledge or changes in behavior explained improved treatment outcomes.(10) Before having any expectations in behavioral changes, these patients were successful because they themselves believed that the treatment control came from them and not just from their doctors.

Maslow’s Self-Actualization
Another possible new intervention strategy in substance abuse public health message is the incorporation of Maslow’s self-actualization principle. Self-actualization is “the instinctual need of humans to make the most of their unique abilities and to strive to be the best they can be.”(8) Self-actualization is “the intrinsic growth of what is already in the organism, or more accurately, of what the organism is.”(8) Maslow writes the following of self-actualizing people: 1) They embrace the facts and realities of the world, including themselves, rather than denying or avoiding them. 2) They are spontaneous in their ideas and actions. 3) They are creative. 4) They are interested in solving problems; this often includes the problems of others. Solving these problems is often a key focus in their lives. 5) They feel closeness to other people, and generally appreciate life. 6) They have a system of morality that is fully internalized and independent of external authority. 7) They judge others without prejudice, in a way that can be termed objective.(8) In short, self-actualization is reaching your fullest potential.

Substance abuse public health messages should target and be applicable at different phases of addiction, from occasional habitual users to severely dependent abusers. One proposed method would be stages-of-change intervention messages incorporating Maslow's hierarchy of needs integrated at various stages of addiction. Such method would allow each user to define his/her own level of addiction along with recovery pathways ranging from self-change to seeking professional treatment.

Conclusion
Substance abuse public health messages and education campaigns can inadvertently lead one to deny one’s substance addiction due to stigmatization of substance abuse individuals. Generally, people do not like to belong to a group labeled as problematic and deviant. By taking a dichotomous approach in substance abuse, past public health messages narrowly targeted the general public – the severe individuals of substance abuse. For less severe users, these messages would only bring resistance and/or denial. By transitioning from this dichotomous approach to the continuum approach of substance abuse, the public would be able to choose multiple pathways to recovery.

References:
(1) Becker, H. (1963) Outsiders: Studies in the Sociology of Deviance, New York: The Free Press.

(2) Cahalan, D. (1987) Studying Drinking Problems Rather Than Alcoholism, Plenum: New York.

(3) Chiauzzi, E.J. and Liljegren, S. (1993) Taboo topics in addiction treatment: An empirical review of clinical folklore. Journal of Substance Abuse Treatment. 10, 303-316.

(4) Chin R, Benne KD. (1976) General strategies for effective change in human systems. In Bennis W et al. (eds.): The Planning of Change (3rd edition), pp. 22-45. New York: Holt, Rinehart and Winston.

(5) FRAMING PUBLIC ISSUES (2002) FrameWorks Institute.

(6) Klingemann H., et. al (2001) Promoting Self-change from Problem Substance Use: Practical Implications for Policy, Prevention and Treatment, Kluwer Academic Publishers.

(7) Klingemann H., Sobell L. (2004) Promoting “natural recovery” from addiction and social support: Towards a self-change friendly society. Bridging the GAP: European Alcohol Policy Conference.

(8) Maslow, A. H. (1943). A Theory of Human Motivation. Psychological Review, 50, 370-396.

(9) Müller, R., Weiss W. (1984) Das Bild des Alkoholikers in der Öffentlichkeit. Scheweizerische Fachstelle füur Alkoholprobleme: Lausanne.

(10) Pincus T, Esther R, DeWalt DA, Callahan LF. (1998) Social conditions and self-management are more powerful determinants of health than access to care. Annals of Internal Medicine 129:406-411.

(11) Siegel M. Education and persuasion versus coercion as public health approaches. The Rest of the Story: Tobacco News Analysis and Commentary (blog). May 4, 2006.

(12) Sobell, L.C., Cunningham, J.A. and Sobell, M.B. (1996) Recovery from alcohol and problem with and without treatment: Prevalence in two population surveys. American Journal of Public Health, 86(7), 966-972.

(13) Sobell, L.C., Sobell, M.B. and Toneatto, T. (1992) Recovery from alcohol problems without treatment, in Self-control and the Addictive Behaviours, Maxwell MacMillan: New York.

(14) Vaillant, G.E. and Milofsky, E.S. (1984) Natural history of male alcoholism: Paths to recovery, in Longitudinal Research in Alocoholism, Kluwer-Nijhoff Publishing.

(15) http://www.recoverymonth.gov/outcomes/2005outcomes/outcome6.aspx#1

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