Is it a substance use disorder or is he a substance abuser?

Jan 15 2010 Published by under Drug Abuse Science, Public Health

ResearchBlogging.orgThis is awesome. I've been waiting for the paper to show up ever since I saw the poster presentation at a meeting last year. Or maybe I just saw a related type of poster because I seem to recall the analysis being particularly critical of general medical doctors? At any rate, this is a pretty important finding because it speaks to the stigma that surrounds certain types of medical problems. This stigma might have serious implications for judicial decision making when crimes are involved, personal health care recommendations / efforts from physicians, etc. The paper is in the queue at the International Journal of Drug Policy.
Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms
John F. Kelly and Cassandra M. Westerhof, International Journal of Drug Policy, In Press, Corrected Proof, Available online 14 December 2009, [DOI]
I was alerted to the publication by the description here at Science Daily.

The investigators randomly distributed surveys to more than 700 mental health professionals attending two 2008 conferences focused on mental health and addiction. The surveys began with a paragraph describing the current situation of "Mr. Williams," who is having trouble adhering to a court-ordered treatment program requiring abstinence from alcohol and other drugs. On half of the surveys, he is referred to as a "substance abuser;" on the others, he is described as having "a substance use disorder," with the rest of the narrative being exactly the same. The survey consisted of 32 statements about Mr. Williams' situation, and participants were asked to indicate how much they agreed or disagreed with those statements.


Subjects were mental health care providers recruited at two substance abuse related conferences in the fall of 2008. The 516 responding subjects completed a series of Likert-scale (1-6; strongly disagree to strongly agree) evaluations of statements such as the following.

His problem is caused by a reckless lifestyle
Mr. Williams is responsible for causing his problem
Mr. Williams' problem is God's will
He should be given some kind of jail sentence as a "wake up" call
Mr. Williams should be referred to a spiritual or natural healer
I believe he will do something violent to others
The judge should increase the severity of the consequences for any further alcohol or drug use
His problem is caused by the way in which he was raised
Mr. Williams could have avoided using alcohol and drugs

The investigators then performed an exploratory factor analysis- a statistical procedure in which the idea is to find groups of statements for which the answers tended to be correlated. From this they extracted three principal statement-grouping factors characterized as "perpetrator-punishment", "social threat", and "victim-treatment". The major focus of the study was on the independent manipulation of whether the narrative described the subject as "a substance abuser" or a person "with a substance use disorder". No group differences were found for social threat ("I would be willing to have Mr.Williams as a neighbor") or victim-treatment ("Mr. Williams' problem is caused by a chemical imbalance in the brain") type of statements. However, the characterization of "a substance abuser" or "with a substance use disorder" did influence responses on the perpetrator-punishment statements ("In order to help Mr.Williams stay on track, the judge should initiate disciplinary action").

those assigned the "substance abuser" term .. were significantly more in agreement with the notion that the character was personally culpable for his condition and more likely to agree that punitive measures be taken

The authors describe the statements which cluster in this perpetrator-punishment group as follows.

Overall, items associated with this subscale appear to convey internal causal attribution and personal culpability, a moral vs. medical solution, suggesting the character has volitional control and might be viewed as a "perpetrator"who is willfully engaging in the behavior and thus more deserving of punishment.

So the take home here is that we should endeavor to focus our descriptors on actions and diagnoses rather than on terms which imply essential characteristics of a person.
The authors do caution that their effect size was pretty small and the connection to real-world decision making unclear. But I buy their argument that since these were substance-abuse experienced mental healthcare professionals, one might expect this to be the floor of the effect. Those such as legislators, judges and even doctors who do not specialize in substance abuse might be predicted to be even more influenced by the way they perceive substance use. If perceiving it as a volitional or moral failing, they are likely to be more punitive and select less therapeutic options, I would argue.
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Kelly, J., & Westerhoff, C. (2009). Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms☆ International Journal of Drug Policy DOI: 10.1016/j.drugpo.2009.10.010
Massachusetts General Hospital (2010, January 14). Words used to describe substance-use patients can alter attitudes, contribute to stigma. ScienceDaily. Retrieved January 14, 2010, from http://www.sciencedaily.com/releases/2010/01/100113122310.htm

13 responses so far

  • David says:

    physicians outside the mental health area have understood this for years: he's a patient with diabetes, not a diabetic. Or epileptic. It's the presumed moral superiority of the doctor treating substance abuse and some other behavior disorders that brings out the judgemental.
    Great paper. thanks for posting it. You are truly a person with blogging habits.

  • This is fantastic, Drug - real data on something I would've guessed, although I'm disappointed that these trends came from a survey of mental health professionals, not the general public.
    I just wrote the other day on my disdain for the phrase, "patients who failed treatment X," that is used commonly in clinical oncology. Words matter and they influence attitudes whether you realize it or not, no matter how much education you have or how immune you may think you are to bias.
    Great review of a great study.

  • PalMD says:

    I'm wondering what differences there would be in a group of internists vs mental health professionals, given that they may approach these terms and diagnoses differently and have different exposures to them.
    I'd love to see follow up work on tobacco use disorders and heart disease, and doctors' perceptions, and also, perhaps, an extension to type II DM (often viewed right or wrong as a will power disorder) and how physicians' perceptions influence treatment.
    This is some interesting stuff.

  • JD says:

    Wow, that was really cool. It can be remarkable how much the way we frame a problem can influence the way we address it.
    Thank you of posting this!

  • Mark says:

    Reminds me of Cryptonomicon where Bobby Shaftoe was referred to with the German word literally meaning "Morphine-seeky," rather than as an addict. The first term "modifies Bobby Shaftoe, where the second one obliterates him completely."
    Awesome book. Too bad they wouldn't let me bring it into inpatient treatment as it wasn't "of a spiritual nature."

  • Wow. I'd love to see how severe the trend would (or not) be if the general public were surveyed. Though then we'd probably have to include the options "Mr. Williams made a pact with the devil" and "Mr. Williams is a product of the liberal elitist mindset" to gauge the full reaction of the public!
    Seriously though, I wonder what would happen if the introductory paragraph included another variation: That it introduced Mr. Williams simply as a black man in one version or as a church-going, white, middle executive with a wife and kids in the other. I think I have a pretty good guess on how that'd turn out but it would be nice to see the data.

  • Actually, a simple and brutally honest survey (not practically feasible, I think) would be to just hand out the same literature and see how many people made any associative inferences about the ethnicity of Mr. Williams.

  • Isabel says:

    JD said: "Wow, that was really cool. It can be remarkable how much the way we frame a problem can influence the way we address it. "
    Now DM if you could just imagine how framing ALL plant intoxicant use as pathological in some way, for example by referring to all use as "abuse" as your NIDA director does, or our oft-stated goal of a "drug-free" society (this is understood to refer to intoxicants only), influences how we address the issue of such use, including use by otherwise productive and law-abiding members of society.
    If we could just focus all our efforts and taxpayer dollars on those who have a "substance use disorder" and stop labeling everyone who uses a "drug abuser" our subsequent actions might end up being more rational.
    Research into the health effects of a drug, just like anything else we put into our bodies, is fine of course. But when we end up with innocent (i.e. people who do not have a substance abuse disorder) people arrested and forced by judges into "treatment", something is wrong with not only how we are approaching the problem, but our very perception of what the problem is.
    Drug prohibition as a solution to dependency problems in a small minority of users can only be accepted as a solution if we don't view drug use as the expression of a normal desire and a normal, while perhaps not necessary, part of human life.
    "That it introduced Mr. Williams simply as a black man in one version or as a church-going, white, middle executive with a wife and kids in the other."
    It doesn't sound very scientific to contrast "simply" a black man with a complex description of a white man. Why not four versions: a black man, a white man, a church-going, black, middle executive with a wife and kids, and a church-going, white, middle executive with a wife and kids.

  • I find it a just as interesting matter of semantics that in my bailiwick of advocacy where I am dealing more with politicians, law enforcement, and suffering families that the use of “disorder” or any other disease concept terminology is likely to produce the opposite effect. These groups are more often than not willing to accept the actions of alcoholic and addicts without prejudice, but will react with scorn and disbelief when asked to consider them at least partly the consequence of a complex medical condition. Much of this is probably caused by the fact that addicts and alcoholics can be pathological liars and those that have been to deal with this on a daily basis consider the disease concept just another convenient excuse.

  • Mike Olson says:

    *Mark*#5: I thought that was a neat concept too. I tend to see any addiction or repetitive behavior as a learning process. Of course there is a matter of whether the behavior learned is positive, negative or a mixture of the two. Simply labeling a person as an addict or non-addict seems to create a binary world in which there are no shades of gray, no real room for those who've learned to drink without any of the normal associated genetic predispositions and those who found themselves over-indulging quickly, and self-labeled due to genetic predispositions. In short, I see this as a matter as nature and nurture intertwined in such a way that claiming any particular all encompassing characteristic behavior on one issue as being ridiculous. Life is not one size fits all and not all folks with such issues are pathological liars or ready to sell their children(or their soul) to use.

  • ginger says:

    Mark @ 5 - You weren't permitted to bring reading material into inpatient (drug/alcohol?) treatment unless it was "spiritual"? That's appalling. Who gets to define what's spiritual? What do you do if you're not into the numinous? This wasn't publicly funded treatment in the US, was it?

  • DuWayne says:

    On the one hand, this actually supports my notion of a linguistics approach to addiction treatment - on the other hand, I am not sure I like what it actually has to say.
    I am especially interested in what the reaction would be to the term "addict" as apposed to "substance abuser," which are two different points on the same spectrum. It is far easier to moralize habitual users and substance abusers, because neither really implies overt mental illness. This in spite of the fact that substance use disorder would include not only substance abusers, but habitual users as well (something I do not particularly approve of, btw).
    What disturbs me about this, is that "substance abuse disorder" is not a specific diagnosis, it is the spectrum for diagnosis. Whether the label is taken any further than therapy or not, it is rather important to make the distinction between habitual use, substance abuse and addiction.
    Quite honestly, if you are talking to someone who was ordered by the court for treatment and it turns out they are an habitual user, about the only thing that you can do is discuss their patterns of use - help them understand what to look out for in terms of their use turning into abuse or addiction and leave it at that. If they are seeking help voluntarily, you are going to employ considerably different methods for treating them, than you would a substance abuser or addict. You simply cannot just sit there and pretend they are an addict and treat them accordingly. Dealing with a habitual user, one should be taking more of a preventative approach mixed with a smattering of behavioral therapy. It is also a good time to talk about what in life is driving this desire to escape - keeping in mind that general dissatisfaction or the simple need to unwind is not uncommon.
    And if they are a substance abuser, as apposed to an addict, you are also going to proceed differently. One must treat this on the basis of patterns of use. Substance abuse is the point on the spectrum when the user has definitely lost control over their use and when there may be some notable negative effects to their use. This is the point when a good therapist is going to really focus on the individual and tailor treatment to their specific needs. Behavioral therapy should be part of treatment, but at this point it is important to recognize that there is necessarily going to be more that needs to be considered.
    Then you get to overt addiction - now you are adding serious damage control to the entire mix. Instead of just dealing with the substance use patterns, you are also dealing with the damage those patterns are causing. Your first priority should be minimizing the damage - adjusting the patterns of use to reduce damages. Even as you develop a plan for creating a permanent solution (usually abstinence), you must help the addict become functional - all the while accounting for the denial and cognitive dissonance that carries one from casual use, into full fledged addiction.
    While there is a great deal of crossover between then categories - remember this is a spectrum, it is critically important from a treatment standpoint to make these distinctions. It is also critically important as a therapist, not to pass moral judgments about clients. This is just as true of a habitual user who is satisfied with their pattern of use, as it is of an extreme addict who has lost all semblance of control. Developing a relationship with a client that is based on trust is critically important, if you are going to have any impact at all. If they do not trust you, do not see you as an advocate for their self-interest, you might as well forget about it - you are never going to do a damned thing for them.
    Moralizing amongst substance abuse professionals is extremely disheartening. I understand where it comes from - substance abusers and addicts are quite often a huge pain in the behind, some of the most difficult clients to deal with. But it isn't like we can just eliminate these terms wholesale - they are important labels when it comes to dealing with clients - or should be.

  • anonymous says:

    I'm both. And mentally ill in other ways. Go stick *that* five meters into your Oppression Olympics hole. (*And* it's *not* a mistake to cross the motherfucking street when you see me coming!)

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