Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Tuesday, December 11, 2007

Talk about Addiction: Starting the Conversation or Enforcing Social Stigma? – Meghan Gavaghan

Addiction is a topic that is discussed often in public health. This disease engenders much research into prevention and treatment and its effects on the person, family, and community of those afflicted. In an effort to increase awareness of addiction as a disease, the Department of Public Health in Massachusetts, Bureau of Substance Abuse Services, is currently running public service radio announcements. These announcements serve to raise awareness of substance abuse and the inability of those addicted to get the services they need because of the social stigma attached to the condition. It is quite admirable for the Bureau of Substance Abuse Services to attempt to institute this kind of shift in public opinion that is certainly a barrier faced by people who need treatment to recover from dependency on drugs and alcohol. The method in which the Bureau goes about trying to shift the frame of the discussion of the treatment of substance dependency, however, ultimately is not effective in its implied goal of changing the social norms and stigmas associated with addiction and increasing the access to treatment. The Bureau’s apparent attempt at utilizing the Health Belief Model, its attempt at using communications theory, and its focus only on the social stigmas associated with addiction as the only barrier to accessing treatment all conspire to limit the campaigns overall effect on changing the social stigma associated with addiction and allowing more people to receive the treatment they desire.

The Talk About Addiction program instituted by the Massachusetts Department of Public Health, Bureau of Substance Abuse Services, is ambitious in its goals. In addition to running radio announcements on radio stations in the greater Boston area (see Appendix I), a website supports further learning and online tools to encourage the general public to think differently about addiction (1). The announcements provide dramatic examples of the labels and derogatory language that is often used to describe those with substance dependence. The intended audience appears to be those in the general public that have the belief that substance dependence is within the control of the user and is not a disease that can be treated like any other disease. This, however, is not clearly stated in the announcement, but rather is left up to the listener to interpret whether or not the announcement applies to them. In addition to personal accounts, the announcement discusses the current discrepancy between those who suffer from substance abuse and those that seek treatment. As stated in the announcements and cited on the website, “Only one out of ten Americans with drug and alcohol problems will get the help they need…” (1) and further states that, “…together, we can change this troubling statistic,” (1). The announcement further direct listeners to http://www.talkaboutaddiction.org in order to get more information on addiction and how to best help those who need treatment services. The website provides further personal accounts, information on prevention, information regarding stigma and how stigma affects the treatment of substance dependence, and treatment avenues for those dependent on substances. The website also pays particular attention to the role of health care providers and employers in recognizing addiction and treating those with dependence with dignity devoid of stigma.

There are some clear limitations to the program that should be discussed prior to delving further into the effect that this intervention has on achieving the goal of alleviating the social stigma associated with substance dependence. First, the radio announcement was broadcast on an AM radio news station (WBZ1030, Boston) which may limit the number and demographic of people who hear the announcement. Secondly, the announcement itself does little to inform the public on stigma and substance dependence and relies on the website to convey information. Lastly, access to the information within the Bureau’s website is incumbent upon one’s access to the internet. This could limit those who are in fact exposed to the information meant to change the social stigma. Looking beyond the surface level of the intervention, however, it appears as though the Bureau’s program could be effective in starting the conversation with regards to eliminating the stigma attached to substance dependence and allowing those who need treatment to get it. A closer look at the behavior models and theories that appear to be behind the development of the intervention, though, shows that the Massachusetts Department of Public Health, Bureau of Substance Abuse Services, fails to effectively use social science theory to inform its intervention and therefore fails to shift the conversation away from stigmatization of those with substance dependence.

Before further discussing these limitations, it is important to discuss the link between stigma and substance dependence and the subsequent diminished access to treatment. Social stigma was characterized in an essay in the Lancet in February of 2006 by Link and Phelan as arising from 5 components. These components include labeling a person as different, linking that different person to undesirable characteristics, and then separating that different person from oneself, or stigmatizing. The different person then experiences discrimination based on those perceived undesirable characteristics, which is followed by a loss of social, cultural, economic, or political power (2). Further describing the effect of stigma, researchers have shown through a study of the societal framing of a diagnosis of mental illness or substance abuse that, “…both conditions were ranked as among the most stigmatized of 18 conditions, roughly on par with being ‘dirty and unkempt’ and having a ‘criminal record for burglary’,” (3). As a result of these stigmas, Link and Phelan go on to discuss the fact that the loss of power or control over one’s destiny puts the individual, who is already suffering from the disease of addiction, at a greater disadvantage in seeking redemptive treatment. Clearly, stigma of this magnitude that is perpetuated in society is a barrier to treatment faced by those with substance dependence and the Bureau of Substance Abuse Services was justified in attempting to alleviate this social burden on those persons seeking substance dependence treatment. While the Bureau of Substance Abuse Services was well-intentioned in attempting to change the conversation around substance dependence in the view of the general public, the intervention that they chose to implement failed to utilize or fully realize social science theory in a way that would effectively reach their target audience and assist those with substance dependence to truly get the help they need.

Health Belief Model – Informing or Detracting from Intervention?
In looking at the behavioral theory that this intervention could have been modeled after, it would appear that the designers were using the Health Belief Model to inform its creation. This is likely, as it is a widely utilized framework in many public health interventions (4). As discussed in Irwin Rosenstock’s summary article discussing the model, the Health Belief Model describes health behavior of the individual as a rational, balanced examination of the perceived susceptibility of a condition and the perceived seriousness of that condition weighed against the perceived benefits of and barriers to taking an action to prevent the condition (5). The inherent drawback of using the Health Belief Model is that the social aspect of decision making, in this example especially the stigma of substance dependence, is not taken into consideration during the process. As discussed by VanLandingham in his research on the influence of the Health Belief Model and the Theory of Reasoned Action on sexual practices among Northern Thai men, the author states that, “perhaps the most serious [problem] being its emphasis on the perceived costs and benefits of health behaviors and its relative neglect of personal and social factors,” (4). He goes on to say that, “One particular social factor that is difficult to incorporate into HBM…is peer group influence,” (4). In other words, an intervention developed using the Health Belief Model as a guide assumes that, when given the necessary information, a person will make a rational choice to follow that information regardless of the social pressures to do otherwise.

The disregard of the social pressures that frame the perceived costs and benefits of a health behavior is what ultimately detracts from the effectiveness of the Talk about Addiction campaign. The program is designed around the information provided to the listener of the radio announcement and the viewer of the website. It rests upon the assumption that once those listening to the announcement hear the personal struggles of those relaying their experiences of the stigma attached to substance dependence and those visiting the website see the statistics on addiction and how difficult addiction is to overcome (the perceived susceptibility and perceived severity aspects of the Health Belief Model) that they will rationally decide to treat addiction as a disease. This is in direct conflict with the widely accepted social norm that addiction is something that is completely in control of the individual and a weakness of the individual. The assumption that the testimonials will drastically change people’s opinions is misguided. One reason the testimonials may not have the desired effect is that the listener may not identify themselves as someone who agrees with the social norm that those with addictions are completely in control of their condition. The belief that substance dependence is not a treatable disease is most likely a subconscious belief that cannot be readily identified through self-reflection. Therefore, the listener may ignore the message that the radio announcement is trying to convey simply because they don’t realize that they harbor the belief that individuals are in control of their addictive tendencies. Also, the listener may not have any experience in dealing with a person with substance dependence and therefore may be unaware of the prejudices and preconceived notions that they harbor toward addicted individuals. The social norm, or the stigma associated with substance dependence, is the perceived barrier to the audience in making a change behavior and, considering the strength of stigma in society, is strong enough to dissuade any change in behavior on the part of the listener or viewer.

The Bureau of Substance Abuse Services could have improved upon the development of their intervention and reached a greater proportion of the general public by utilizing behavior theory that takes into account the importance of social norms and stigma in deciding behavior. One possible alternative would have been to consult the concept of diffusion of innovations theory to better influence a change in the social stigma associated with substance dependence. As discussed in the text by Edberg, this theory rests upon the idea that innovations, or new ideas and concepts, become part of society through a process of learning and adoption. The adoption of the new ideas begins with some smaller group of influential early adopters and then slowly diffuses throughout the society based on the success or acceptance of that new idea or concept. This theory originated in the development and acceptance of new technology, but can be applicable to social ideas as well (6). With this theory in mind, there is a body of evidence that suggests that health care providers would be an excellent group to focus on as early adopters of the idea that substance dependence is a disease that can be treated and should not be stigmatized as it currently is in society. Kay Redfield Jamison recently wrote an essay for the Lancet based on her own experience of mental health and substance dependence and the lack of clear understanding of these conditions as disease in the health care practitioner community. As she discussed when referring specifically to mental illness, “Unless we are willing to talk about how to deal with mental illness among professionals the problem is going to remain undiscussed, creating more fear and more stigmatization…Some of the stigma associated with mental illness exists because there has been so much bad teaching and inadequate treatment over the years,” (7). This idea is further supported by Bruce Link in a research study regarding the consequences of stigma on men with both mental illness and substance dependence. In his discussion of the findings of the study, he addresses the need to recognize the stigma that exists within the health care provider community that is a significant obstacle to treatment. He states, “Health care providers are therefore faced with the challenge of how to address stigma in its own right if they want to maximize the quality of life for those they treat and maintain the benefits of treatment beyond the short term,” (8). While focusing the intervention of the Bureau of Substance Abuse Services to a much more narrow audience of just health care providers, it could have more impact on actually changing public perception. Health care practitioners are respected members of society and if they begin the process of shifting the stigma of substance dependence, the general public is more likely to find it acceptable to treat substance dependence in that way, as well.

Radio – Effective Communication or Ineffective Source?

Despite the shortcomings of the Bureau of Substance Abuse Services apparent reliance on the Health Belief Model to inform the development of their intervention, the Bureau did make an excellent decision in attempting to use communications theory to enhance the effectiveness of the intervention. As discussed in the text by Edberg, communications theory, “aims to impact the agenda of what people are concerned about, in order to set the stage for or prompt action,” (6). By utilizing the media of radio to transmit the message of the intervention, the Bureau is attempting to set the agenda regarding the stigma associated to substance dependence and get the general public to think about the way we as a society treat those with dependence. On the surface, this seems like a very effective method of communication. In the radio announcements, very personal and impactful stories convey the damage that stigma can have on the treatment process for those dependent and those testimonies serve to try to persuade the general public to think differently about dependence.

It may be very difficult for the general public to identify with those in the radio announcement, however, because they are simply hearing a voice and not seeing the person. A major aspect of communications theory, as discussed by Edberg, is the encoding of information by the sender of the information (the Bureau) and the decoding of that information by the receiver (the general public). In the case of the Bureau’s message, the intent of the Bureau is that the general public will identify with the voices in the radio announcements and sympathize with the testimonials given with regards to the stigma associated with substance abuse. This emotional reaction to the radio announcement will encourage them to then shift the attitudes and stigmas they have associated with substance dependence. Edberg discusses the importance of choosing the proper channel within media to convey the message, as this is essential to the proper decoding of the message given by the Bureau. There is certainly a difference between reading a newspaper announcement, hearing a radio announcement, and viewing a television announcement. Edberg notes that, “selection of channels is important in health communications because, as we have noted, the channel itself is relevant to the meaning of the message and because some channels are better than others for reaching a particular group,” (6). The choice of the Bureau of Substance Abuse Services to utilize radio announcement rather that television limits the ability of the audience to decode, or interpret, the message that is being conveyed within the announcement.

The importance of the medium of communication is further supported in The Psychology of Radio, a book focused specifically on radio and its effect as a form of media. When discussing the limitations of radio, the author specifically mentions the lack of a visual element in diminishing the effectiveness of radio in advertising. He states, “Many products are much more significantly presented to the reader through photographs or artistic delineation than spoken word. No verbal portrait alone can do justice to stream-lined automobiles, to a pearl necklace, to the new styles of Paris…..pictorial reproduction of the product provides a valuable identifiability that radio cannot achieve,” (9). While this discussion focuses specifically on advertising of product, the general concept can certainly be applied to the intervention created by the Bureau of Substance Abuse Services. The Bureau, in trying to eliminate the stigma associated with substance abuse, is relying on the stories of those afflicted by stigma to persuade the general public to change their opinions, but this persuasive effect will not reach its full potential via spoken word without visual support. The Bureau could argue that the website associated with the intervention does provide that visual component, but those in the general public listening to the radio announcement may not be persuaded enough by the verbal testimonials to even go to the website to learn more. By focusing first on the auditory message of the testimonials and then the visual message conveyed on the website, the Bureau erroneously assumes that any use of communication theory is effective, rather than focusing on the most effective media, television or print advertising. The failure of the Bureau in capitalizing on a very persuasive media of print or television media diminishes its effectiveness in achieving the goal of alleviating the stigma of substance dependence and the inability of those afflicted to receive treatment.

Stigma – The Only Barrier to Treatment?
A final criticism of the intervention developed by the Bureau of Substance Abuse Services is its focus only on the effect of stigma on the inability of those suffering from substance dependence to receive treatment and the subsequent reliance on community or societal change to enhance the ability of those suffering from dependence to get the treatment needed. As discussed earlier, the effect of stigma is quite significant on the ability of those who are dependent to seek treatment, but it is certainly not the only barrier faced. The self-efficacy of the dependent person, the inability of the person to afford treatment programs, the lack of treatment facilities in one’s area, and the responsibilities of work and family are just a few other important aspects of the decision for a dependent person to seek treatment (10). The Bureau’s focus solely on the stigma associated with substance dependence diminishes its effectiveness in the goal of allowing those affected to receive treatment because stigma may not be the primary reason that a person does not seek formal treatment. By narrowing the focus of the intervention in this way, the Bureau further alienates those who have very different reasons for not seeking treatment. One particular group for which this is a relevant issue is women who are dependent on substances. Not only are treatment programs focused on women’s health limited in number, there are myriad individual and social characteristics that limit women’s ability to access treatment beyond stigma. Copeland notes that, “…the social costs of family disruption…inadequate training of health professionals to detect problem drinking among women, lack of women-only treatment services that also provided childcare, and lack of economic resources and insurance coverage,” (10) were all cited as reasons women did not seek formal treatment for their substance dependence. Additionally, many women are the primary caregivers for dependent children and those obligations were a major obstacle for seeking treatment for 28% of women who had dependent children at the time of their alcohol and other drug problems (10). Even after considering the difficulty in finding care for dependent children, women were also concerned that they could lose custody of their children altogether. The additional social stigma of having deficient maternal instincts furthered their addictive behaviors. The author concludes the article with a call for a holistic approach to the treatment of substance dependency, focusing not only on the stigma attached to substance dependence but also the financial cost of treatment and familial disruption that can affect a woman’s choice to seek treatment. By not addressing these other barriers to treatment, the Bureau of Substance Abuse Services fails to fully realize the goal of getting addicted individuals the treatment they need.

Future Interventions – Informed by the Past, Inclusive of All
In light of the three criticisms outlined above, further study of the intervention created by the Bureau of Substance Abuse Services is necessary in determining the actual effect of the radio announcements and website on changing the stigma associated with substance dependence. Without a qualitative analysis of the general public’s views on substance dependence before and after the intervention, the criticisms discussed in this critique may not be implemented in future intervention planning. The disregard of past successes and failures in the development of public health interventions leads to the repetition of previously unsuccessful initiatives (11). Perhaps if the lessons from past campaigns had been incorporated into the development of the intervention from the Bureau, we would have seen a more focused campaign. A more effective intervention would have featured a focused approach, perhaps on health care practitioners using the theory of diffusion of innovations to diffuse the concept of substance dependence and a disease from health care practitioners to the general public. It also would have included print and television announcements featuring the persons heard in the radio announcements to enhance the general public’s decoding, or understanding, of the impact of stigma on those suffering from substance dependence. Finally, the intervention would have addressed other barriers to seeking treatment, such as the cost of treatment and child care, those subpopulations such as women face in seeking treatment to enhance the goal of increasing the accessibility of treatment. Instead, the Bureau of Substance Abuse Services has produced an intervention that is limited in its ability to change the stigma associated with substance dependence and ultimately does not increase access to treatment. Future interventions developed by the Bureau of Substance Abuse Services should be informed by these research studies and the entire breadth of socials science to enhance their effectiveness in creating social change. The Bureau of Substance Abuse Services certainly begins the conversation regarding the stigma associated with substance abuse, but the intervention does not achieve its ultimate goal of getting the substance-abusing population the treatment that they need.

APPENDIX I.
In order to further understand the method of intervention used by the Massachusetts Department of Public Health, Bureau of Substance Abuse Services, I have transcribed the three different radio announcements. You can also hear audio of the radio announcements at http://www.talkaboutaddiction.org/listen/. The first example utilizes many different voices to convey the message, while the other two examples utilize one person conveying their own life experience.

Dreams
“When you were young, did you dream about being addicted? Did you dream about having a problem with alcohol? With tobacco? With drugs? With gambling? People who struggle with addiction didn’t have that dream either. The truth is, no one chooses to be addicted because addiction is a disease, a disease that can be treated like any other and when treatment works, people do recover. Families recover. Communities recover. We need to start talking, talking about why we make people who struggle with addiction feel so ashamed. Talking about why only one out of ten Americans with drug and alcohol problems will get the help they need. Let’s start the dialogue. Learn more about how addictions affect all our lives. Visit http://www.talkaboutaddiction.org sponsored by the Massachusetts Department of Public Health, Bureau of Substance Abuse Services. Start the dialogue. Visit http://www.talkaboutaddiction.org.”

Hope
“If your mom was addicted to cocaine, to crystal meth, to marijuana, would you call her a junkie? A burnout? A pothead? I am a mother, a mother of five, and I struggled with addiction for many years. I was called all those names and more and, after a while, I believed I was that junkie, that burnout, that pothead. I believed there was no hope for me. But there was hope because addiction is a disease, a disease that can be treated. And with support and treatment, it’s possible for people, families and communities to recover. I know. I’m one of those people. Only one out of ten Americans with drug and alcohol problems will get the help they need. Together, we can change this troubling statistic. Let’s start the dialogue. Learn more about how addictions affect all our lives. Visit http://www.talkaboutaddiction.org sponsored by the Massachusetts Department of Public Health, Bureau of Substance Abuse Services. Start the dialogue. Visit http://www.talkaboutaddiction.org.”

Pain
“A drunk? A degenerate? A loser? It’s what people used to call me. People like my boss, people like my wife. After a while, I believed them and I would drink more to mask the pain. They thought I could stop on my own, that it was a matter of willpower, but addiction isn’t a choice. It’s a disease, a disease that can be treated just like any other and people do recover, families recover, communities recover. I know. I’m one of those people. Only one out of ten Americans with drug and alcohol problems will get the help they need. Together, we can change this troubling statistic. Let’s start the dialogue. Learn more about how addictions affect all our lives. Visit http://www.talkaboutaddiction.org sponsored by the Massachusetts Department of Public Health, Bureau of Substance Abuse Services. Start the dialogue. Visit http://www.talkaboutaddiction.org.”

REFERENCES
1. Massachusetts Department of Public Health, Bureau of Substance Abuse Services. Talk about Addiction. Boston, MA: Massachusetts Department of Public Health. http://www.talkaboutaddiction.org
2. Link, Bruce G. et al. Stigma and its Public Health Implications. Lancet, 11 February 2006; 367: 528-529.
3. Room, Rebecca. Taking Account of Cultural and Societal Influences on Substance Use Diagnoses and Criteria. Addiction, 2006; 101 (Suppl. 1): 31-39.
4. Vanlandingham, Mark J. Two Views of Risky Sexual Practices Among Northern Thai Males: The Health Belief Model and the Theory of Reasoned Action. Journal of Health and Social Behavior, June 2005; 36 (2): 195-212.
5. Rosenstock, Irwin M. Historical Origins of the Health Belief Model. Health Education Monographs, Winter 1974; 2 (4): 328-335.
6. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston, MA: Jones and Bartlett Publishers. 2007.
7. Jamison, Kay Redfield. The Many Stigmas of Mental Illness. Lancet, 11 February 2006; 367: 533-534.
8. Link, Bruce G. On Stigma and Its Consequences: Evidence from a Longitudinal Study of Men with Dual Diagnoses of Mental Illness and Substance Abuse. Journal of Health and Social Behavior, June 1997; 38 (2): 177-190.
9. Cantril, Hadley. The Psychology of Radio. New York, NY: Harper & Brothers. 1935.
10. Copeland, Jan. A Qualitative Study of the Barriers to Formal Treatment Among Women Who Self-Managed Change in Addictive Behaviours. Journal of Substance Abuse Treatment, 1997; 14 (2): 183-190.
11. Hallfours, Denise. Fighting Back Against Substance Abuse: Are Community Coalitions Winning? American Journal of Preventative Medicine, 2002; 23 (4): 237-245.

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