Roman Spring 2006

Stigma Associated with Substance Abuse and Dependence: The Effects of Socio-Cultural, Political and Treatment Contexts: 

Stigma Associated with Substance Abuse and Dependence: The Effects of Socio-Cultural, Political and Treatment Contexts Paul M. Roman Institute for Behavioral Research University of Georgia Presentation at Johnson Institute Seminar, Washington, D.C. April 21, 2006

What is the Problem?: 

What is the Problem? Persons with alcohol problems appear to be equally if not more stigmatized than 25 years ago Stigma impacts opportunities for social interaction, employment and quality of life Stigma encourages cover-up and hiding Alcohol intervention has “second class” status “Medicalization” is much less complete than many people seem to believe.

Stigma: What is it?: 

Stigma: What is it? Stigmata: An evil mark on the body Stigma and the D-words Different Distant Disengaged Disqualified Disabled Damned

Historical Background : 

Historical Background The Temperance Movement creates King Alcohol, a source of evil, but redemption is possible by abstinence…….for everyone. Ultimate “victory” is National Prohibition which “works in terms of reducing alcohol consumption Prohibition is repealed because of high social costs, failure of enforcement, and disrespect for the law. Alcohol re-enters the culture as a legal substance surrounded by ambivalence

Historical background (cont’d): 

Historical background (cont’d) Yale Center, AA and NCA emerge in sequence. Scientists urge for a new approach, de-emphasizing Temperance concepts. AA demonstrates a successful program of recovery that more or less resembles “treatment.” AA emphasizes the physical distinctiveness of drinkers who lose control: “allergy”

Historical background (cont’d): 

Historical background (cont’d) The “disease concept”: identify and help those who cannot drink without losing control. By implication, rejects the “alcohol as evil” concept of the Temperance Movement NCA’s message: A small proportion of drinkers develop the disease of alcoholism. They can be successfully treated via the AA model. NCA is the center of diffusion of the disease concept. Strives to achieve parity between the treatment of alcoholism and other diseases: “A disease like any other.”

Historical background (cont’d): 

Historical background (cont’d) Treatment emerges is not widely available Most identification occurs at the late-middle and late stages of alcohol dependence Recovered alcoholics take leadership roles through NCA to bring about change These leaders recognize that voluntarism is not enough: government involvement is required to create major changes

Historical Background (cont’d): 

Historical Background (cont’d) NIAAA is established 12/31/1970 Strong “primary” and secondary constituencies are created. Like AA, the focus is singularly on alcoholism, NOT drugs or “co-morbidity” The strong message is that alcoholism affects respectable people who can return to respectability…..”People like you and me” The Skid Row bum/public inebriate is explicitly rejected as a possible “poster child”

Historical background (cont’d): 

Historical background (cont’d) Constituencies are partially sustained through NIAAA funding mechanisms Constituency and NIAAA generate 3rd party payments for alcoholism treatment Alcoholism treatment grows substantially and is “isomorphic” (28 day Minnesota Model) Remains explicitly separate from drug treatment

Historical Background (cont’d): 

Historical Background (cont’d) A synergistic combination of EAPs, health insurance coverage, and private treatment availability is established. Large amounts of national publicity about treatment and recovery NCA and its affiliates flourish throughout the country, with much support coming via NIAAA Culmination may be seen in “coming out party of 1976 Much open support by workplace leadership

Historical background (end): 

Historical background (end) NIAAA, NIDA, and NIMH lose their authority for supporting demonstration treatment and prevention as well as block grants in 1981 and become exclusively research agencies An opportunity to transform alcoholism into “a disease like any other” is compromised with the erosion of the constituency The infrastructure of support turns out to be more fragile than was believed.

The Return of Stigma?: 

The Return of Stigma? Stigma associated with alcohol dependence appears to have diminished during the 1970s and 1980s But public champions of alcoholism gradually disappear (go into hiding?); Small but admirable effort currently in Congress; recovering business leaders nearly non-existent Are potential champions afraid to come forward because of anticipated losses?

Return of Stigma? (cont’d): 

Return of Stigma? (cont’d) Managed care assaults alcoholism treatment with little constituency resistance Parity of alcoholism treatment is openly rejected by political leadership without any apparent fear of “backlash” from any significant constituency group

Return of Stigma (cont’d): 

Return of Stigma (cont’d) War on Drugs….makes no distinction about alcoholism Merging of state level funding agencies for alcohol and drug issues Merging of Federal funding for drug and alcohol programming via the organization of SAMHSA vs. NIAAA and NIDA prior to 1981

Return of Stigma (cont’d): 

Return of Stigma (cont’d) Replacement of “recovering” for “recovered” within AA Discussion of alcoholism as “a disease of relapse” Combining alcohol and drug treatment Arguing that polydrug use is the norm rather than the exception “Cavalier” use of the term “addiction” Discovery of highly prevalent dual diagnosis

Return of Stigma (cont’d): 

Return of Stigma (cont’d) All of these factors dilute the imagery that had been created in the 1970s-1980s Alcoholism is viewed as one part of a larger problem of substance abuse Substance abuse is viewed with the lenses of the War on Drugs The disease concept of drug addiction views the addiction as a consequence of personal choice rather than biological vulnerability

The Return of Stigma (cont’d): 

The Return of Stigma (cont’d) 1996 General Social Survey shows stigma of alcoholism to be higher than for depression or schizophrenia Stigma means rejection from social relationships; social exclusion, resulting in low likelihood of positive referral action

New Research Data: 

New Research Data Data generated from the 2001-2002 National Employee Survey conducted by the University of Georgia Nationally representative sample of 4,000 employed adults Responses to vignette descriptions followed by questions about willingness to engage in different “role relationships” with the described person

New Research Data (cont’d): 

New Research Data (cont’d) Alcohol dependence vignette: During the last month, Mary has started to drink more than her usual amount of alcohol. In fact, she has noticed that she needs to drink twice as much as she used to in order to get the same effect. Several times she has tried to cut down or stop drinking, but she can’t. Each time she has tried to cut down, she became very agitated and sweaty and she couldn’t sleep, so she took another drink. Her family has complained that she is often hungover and has become unreliable----making plans one day and canceling them the next.

Percent of Public Sample of Employed People Unwilling to Make Friends…: 

Percent of Public Sample of Employed People Unwilling to Make Friends…

Percent of Public Sample of Employed People Unwilling to Move Next Door…: 

Percent of Public Sample of Employed People Unwilling to Move Next Door…

Percent of Public Sample of Employed People Unwilling to Spend Evening Socializing…: 

Percent of Public Sample of Employed People Unwilling to Spend Evening Socializing…

Percent of Public Sample of Employed People Unwilling to Act As Their Supervisor: 

Percent of Public Sample of Employed People Unwilling to Act As Their Supervisor

Percent of Public Sample of Employed People Unwilling to Work Closely With…: 

Percent of Public Sample of Employed People Unwilling to Work Closely With…

Percent of Public Sample of Employed People Unwilling to Have Marry Into My Family…: 

Percent of Public Sample of Employed People Unwilling to Have Marry Into My Family…

Percent of Public Sample of Employed People Unwilling to Have As My Supervisor…: 

Percent of Public Sample of Employed People Unwilling to Have As My Supervisor…

Other Dimensions of Stigma: 

Other Dimensions of Stigma Public attitudes toward the disease concept reflect confusion: acceptance of both moral and disease models (It is a self-contracted disease due to moral weakness)

Ingredients of Current Attitudes Toward Alcoholism: 

Ingredients of Current Attitudes Toward Alcoholism The War on Drugs and Spillover of “Drug Hatred” Little positive feedback about the effectiveness of treatment (field sets its own impossible standards) Lack of treatment parity “feeds back” into the public view and enforces the “lower status” of the disease of alcoholism Mixed diagnoses will eliminate the role of recovered counselors Treatment programs do not unite for common causes

EAPs: A Case Example: 

EAPs: A Case Example Evolved directly from industrial alcoholism programs with NIAAA facilitation; EAP model diffuses easily with its broad focus EAPs are now accessible to 60% of American workforce: a “platform” with incredible potential for intervention With removal of support by NIAAA, emphasis on alcohol issues has nearly disappeared

EAPs: A Case Example : 

EAPs: A Case Example EAP standards do not require alcoholism or substance abuse skills Training for EAP professionals is minimally available Programs satisfy their management with a reactive programming model; no case-finding or supervisory training Workplace leaders have little knowledge of the potential of EAPs for alcoholism intervention

EAPs: A Case Example: 

EAPs: A Case Example Even if EAP skills are available, employees with alcohol problems are very time consuming and not necessarily rewarding; compare with outcomes where clients want assistance Employees with alcohol problems may be recalcitrant and resistant; given the choice, they will be avoided. Employees with alcohol problems will not come forward on their own; prefer to be left alone Referrals may be problematic with minimal treatment options

Conclusions: 

Conclusions The field lacks champions and constituency is not highly visible War on Drugs has undermined acceptance of the disease concept; re-energized stigma Intermingling of drug abuse and alcoholism in public policy,in diagnoses and treatment causes cultural confusion, may “bring down” attitudes toward alcoholism to parallel those toward drugs Great potential of EAPs has been lost or is dormant

Policy Recommendations: 

Policy Recommendations Constituencies must be mobilized and energized through strong political leadership Reality of stigma must be recognized; talk more to “real world” rather than “insiders”; Stop being enthralled by our own recovery stories There must be structures of reward and motivation to energize potential sources of referral Workplace management and health care professionals must be educated and it will be tough

Recommendations: 

Recommendations Reducing social distance is the key to reducing stigma: How is that accomplished? Workplace programs were a good start in exposing huge numbers of people to the realities of recovery. Does stigma BEGIN with prevention education of children in school settings? Should we have treatment education?