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At The White House, Learning How Not To Talk About Addiction
December 13, 2013
We don’t refer to someone who has anorexia or bulimia as having a “food abuse” problem. We say they have an eating disorder. So why do we refer to someone who is addicted to alcohol or pain pills as having a “substance abuse” problem?
Harvard’s John Kelly, director of the new Recovery Research Institute at Massachusetts General Hospital, made that point this week at what was billed as the first-ever White House summit on drug policy reform. The Obama administration has moved far from the old “war on drugs” model. The current federal drug czar, Gil Kerlikowske, wrote in his email invitation to the summit: “Drug policy reform should be rooted in neuroscience, not political science.” And “it should be a public health issue, not just a criminal justice issue. That’s what a 21st-century approach to drug policy looks like.”
Dr. Kelly, an associate professor of psychiatry, spoke to the summit-goers about the stigma around addiction — so pervasive it can even be seen in language. I asked him to elaborate; our conversation, edited:
It seems clear that addiction is not a good thing. It can cause people many problems, even kill them. But you’re saying that the trouble with addiction stigma is that it goes beyond seeing addiction as bad, to actually blaming the addict?
Yes. The degree of stigma is influenced by two main factors: cause — ‘Did they cause it?’ — and controllability — ‘Can they control it?’ We now know that about half the risk of addiction is conferred by genetics – what you’re born with. On controllability, neuroscience has also taught us that alcohol and other drugs cause profound changes in the structure and function of the brain that radically impair individuals’ ability to stop, despite often severe consequences.
Okay, but what about the other half? There is some element of choice in addiction, at least initially, isn’t there?
Addiction is like many other medical illnesses, in that there’s an interaction between the genetics and the environment. This makes some people more susceptible. For example, a lot of people are exposed to alcohol in our culture, but not everybody becomes addicted to alcohol. The genes may mediate the liking and wanting of that particular substance. For some people, alcohol is aversive for others, it’s kind of okay; for other people, it becomes everything.
So genetics is related to the cause. Brain damage — the toxicity and profound alteration in neurochemical function and structure produced by these abnormally potent reinforcers — alcohol, heroin, cocaine — which causes brain damage — that’s the controllability part. And the language we use directly maps on to that issue of cause and controllability. The rhetoric and language of ‘the war on drugs’ talks about ‘abuse’ and ‘abusers’ and the new movement, toward smarter criminal justice and a more public health approach, needs to look at it as a medical condition and talk about it as ‘substance use disorder,’ which is more accurate medical terminology.
Why does it matter what we call it?
The language we use to describe these problems may perpetuate stigma, and that can potentially harm patients and continue the suffering among families.
New evidence indicates that the commonly used “abuse” and “drug abuser” terms, for example, are conceptually linked to the notion that individuals are at fault for their addiction and therefore should be blamed and punished. These terms fitted well with the “war on drugs” policy approach. In contrast, use of the more medical and scientifically accurate “substance use disorder” terminology is linked more to a public health approach that conveys the notion of a medical malfunction.
We tested the effect of using these terms experimentally. We randomly assigned a paragraph vignette describing an individual in legal trouble due to alcohol and drugs; in half the vignettes the individual was described as “a substance abuser” in the other half he was described as “having a substance use disorder”; otherwise, the scenarios were identical.
Mr. Williams is a substance abuser and is attending a treatment program through the court. As part of the program Mr. Williams is required to remain abstinent from alcohol and other drugs. He has been compliant with program requirements, until one month ago, when he was found to have two positive urine toxicology screens which revealed drug use and a breathalyzer reading which revealed alcohol consumption. Within the past month there was a further urine toxicology screen revealing drug use. Mr. Williams has been a substance abuser for the past few years. He now awaits his appointment with the judge to determine his status.
“SUBSTANCE USE DISORDER”
Mr. Williams has a substance use disorder and is attending a treatment program through the court. As part of the program Mr. Williams is required to remain abstinent from alcohol and other drugs. He has been compliant with program requirements, until one month ago, when he was found to have two positive urine toxicology screens which revealed drug use and a breathalyzer reading which revealed alcohol consumption. Within the past month there was a further urine toxicology screen revealing drug use. Mr. Williams has had a substance use disorder for the past few years. He now awaits his appointment with the judge to determine his status.
Those clinicians exposed to the “substance abuser” term were significantly more likely to judge the person as more to blame and more deserving of punishment than the exact same individual described as having a substance use disorder. We tested these terms in a general population sample and found even larger differences with more negative and punitive judgments strongly associated with the “abuser” term.
These findings indicate that, even among well-trained doctoral level mental health clinicians and addiction specialists, exposure to certain language may create an implicit bias that may result in harsher punitive judgments that perpetuate stigmatizing attitudes toward individuals and families suffering from addiction. These may create barriers to honest self-disclosure and seeking treatment for alcohol or drug problems. This is important as only about 10 percent of affected individuals seek addiction treatment each year and they site stigma as a major barrier.
Does this language effect, which you found makes mental health professionals more judgmental of people with substance use disorders, actually translate into problematic behavior? Like withholding care or benefits?
We don’t know that for sure. That would be very hard to figure out. But what this research is suggesting is that it does produce a kind of implicit cognitive bias toward more punitive attitudes. We do know that attitudes predict behavioral response, however, and we’ve shown that language influences attitudes. So while we can’t prove it, there is a strong basis to believe that it could influence decisions such as withholding benefits or other things from individuals trying to recover from these problems.
You pointed out at the drug reform summit that other mental health fields don’t use the term ‘abuse.’
Right. Individuals with ‘eating-related problems’, are uniformly described as ‘having an eating disorder,’ not as ‘food abusers.’ We need to do the same in the addiction field.
Because the term ‘abuse’ gives rise to the ‘abuser’ term, it is better to use the term ‘misuse.’ Furthermore, given the lack of scientific specificity associated with the ‘abuse’ and ‘abuser’ terms, its nonuse would not result in any loss of scientific accuracy.
When you spoke at the White House, did you explicitly propose that the nation’s drug czar and his staffs and law enforcement more broadly change their language?
Yes, because while rhetoric around language has persisted for years, we now have good evidence that such terms may perpetuate stigma, and stigma is a huge barrier to seeking help.
We need to adopt new language which is more consistent with a public health approach, more accurate and more consistent as opposed to the rhetoric and language of the past — the abuse terminology, which is more strongly associated with a war on drugs approach. One very inexpensive way we can start to alleviate this terrible burden of stigma, which prevents people from seeking treatment, is to drop the old language.
Well, you’ll be up against some very ingrained linguistic habits — I mean, isn’t the federal addiction research agency called the National Institute On Drug Abuse? And you find it at drugabuse.gov. It could be quite an uphill battle to change this language.
If I’d thought of it at the time, I would have said that we do need to change the names of these federal institutions, so they don’t perpetuate this old language. I think it can be an uphill battle, but a battle that is not that difficult to win if we’re really serious about making changes that have an effect on the prevalence of substance use disorders and their impact in the United States. It would reflect a shift toward smarter evidence-based policies. It’ll just be a matter of if we decide finally to let go of that language and adopt new language more fitting, more accurate, and more conducive to the new game in town as opposed to the older war on drugs.
Please spell it out for me: You’re saying that whenever I would have said ‘substance abuse’ I now say ‘substance use disorder’ and for the person, I call them someone ‘with a substance use disorder’?
For example, when we’re talking about it generically, instead of using the term ‘substance abuse,’ many have adopted the term ‘substance misuse.’ And instead of describing someone as a substance abuser or alcohol abuser or drug abuser, you talk about a person who has a substance use disorder or is suffering from a substance use disorder. More broadly, it’s the ‘substance use disorder’ field.
It seems a bit odd when we’re not used to saying these things now; new terms can feel somewhat awkward and strange and foreign at first. But people adapt remarkably quickly; start using the new terms and they become second nature. Human beings are kind of resistant to change and our language is somewhat habitual, so it’s hard to shift our language, but we want to create a stigma against using stigmatizing language.
Is there a new term for the drug policy that has succeeded ‘the war on drugs’? The medical model? The public health approach?
Not formally yet. We could think of one — one that captures a public health and recovery orientation would be good.
The Role of Antidepressants for the Treatment of Bipolar Depression
November 04, 2009
Although rapid-cycling bipolar disorder has been linked to the use of antidepressants, these treatments may still have a role in the management of patients with bipolar depression, said Stephen V. Sobel, MD, clinical instructor at the University of California, San Diego School of Medicine, in a presentation at the U.S. Psychiatric and Mental Health Congress in Las Vegas. Patients with bipolar disorder spend most of their time in depression, and antidepressants can alleviate these symptoms, said Sobel. “That’s why it’s so tempting to treat these patients with an antidepressant. But it’s important to be familiar with recent studies on the development of rapid-cycling bipolar disorder and to weigh the risks and benefits,” he said.
The use of antidepressants may increase a patient’s risk of rapid-cycling bipolar disorder. The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) included 1742 patients treated with a variety of approved medications for bipolar I and bipolar II disorder, and 32% reported having rapid-cycling at baseline. After 2 years of treatment, 5% still had rapid-cycling bipolar disorder. Those who were treated with an antidepressant were 3.8 times more likely to have rapid-cycling bipolar disorder.1
Based on his clinical experience, Sobel has seen positive results when treating patients who have bipolar depression with antidepressants as adjunctive therapy. But physicians should also consider that antidepressants have been shown to be ineffective as adjunctive therapy. In another STEP-BD study, patients with bipolar depression were treated for up to 26 weeks with a mood stabilizer and adjunctive antidepressant therapy or a mood stabilizer and placebo. Results showed that in patients with bipolar depression who were treated with a mood stabilizer, the addition of an antidepressant was no more effective than the addition of a placebo.2
Adjunctive therapy with antidepressants has also been shown to cause an increase in the incidence of symptoms of hypomania or mania. In a study with a 10-week acute phase and a 1-year continuation phase, 150 patients with bipolar I or bipolar II disorder were treated with an antidepressant (bupropion, sertraline, or venlafaxine) in addition to a mood stabilizer. In the acute phase, 11.4% patients switched to hypomania and 7.9% switched to mania. In the continuation phase, 21.8% switched to hypomania and 14.9% switched to mania. In all patients, only 23% experienced a sustained response to the antidepressants.3
Guidelines state that patients with bipolar depression who are treated with an antidepressant should discontinue therapy within 3 to 6 months after achieving remission. However, discontinuation of antidepressants has been shown to cause depressive relapse in these patients,4 said Sobel. He suggests that physicians should use their discretion to determine how best to treat their patients while also keeping the results of these studies in mind.
Religion, Spirituality, and Mental Health
January 10, 2010
Simon Dein, FRCPsych, PhD
Until the early 19th century, psychiatry and religion were closely connected. Religious institutions were responsible for the care of the mentally ill. A major change occurred when Charcot1 and his pupil Freud2 associated religion with hysteria and neurosis. This created a divide between religion and mental health care, which has continued until recently. Psychiatry has a long tradition of dismissing and attacking religious experience. Religion has often been seen by mental health professionals in Western societies as irrational, outdated, and dependency forming and has been viewed to result in emotional instability.3
In 1980, Albert Ellis,4 the founder of rational emotive therapy, wrote in the Journal of Consulting and Clinical Psychology that there was an irrefutable causal relationship between religion and emotional and mental illness. According to Canadian psychiatrist Wendall Watters, “Christian doctrine and liturgy have been shown to discourage the development of adult coping behaviors and the human to human relationship skills that enable people to cope in an adaptive way with the anxiety caused by stress.”5(p148) At its most extreme, all religious experience has been labeled as psychosis.6
Psychiatrists are generally less religious than their patients and, therefore, they have not valued the role of religious factors in helping patients cope with their illnesses.7 It is only in the past few years that attitudes toward religion have changed among mental health professionals. In 1994, “religious or spiritual problems” was introduced in DSM-IV as a new diagnostic category that invited professionals to respect the patient’s beliefs and rituals. Recently, there has been a burgeoning of systematic research into religion, spirituality, and mental health. A literature search before 2000 identified 724 quantitative studies, and since that time, research in this area has increased dramatically.8 The evidence suggests that, on balance, religious involvement is generally conducive to better mental health. In addition, patients with psychiatric disorders frequently use religion to cope with their distress.9,10
In recent studies, at least 50% of psychiatrists interviewed endorse the view that it is appropriate to inquire about their patients’ religious lives.11-13 That patients’ religious concerns have been taken seriously is evidenced by the fact that the American Psychiatric Association has issued practice guidelines regarding conflicts between psychiatrists’ personal religious beliefs and psychiatric practice. The Accreditation Council for Graduate Medical Education includes in its psychiatric training requirement, didactic and clinical instruction on religion and spirituality in psychiatric care.
Religion and depression
Studies among adults reveal fairly consistent relationships between levels of religiosity and depressive disorders that are significant and inverse.8,14 Religious factors become more potent as life stress increases.15 Koenig and colleagues8 highlight the fact that before 2000, more than 100 quantitative studies examined the relationships between religion and depression. Of 93 observational studies, two-thirds found lower rates of depressive disorder with fewer depressive symptoms in persons who were more religious. In 34 studies that did not find a similar relationship, only 4 found that being religious was associated with more depression. Of 22 longitudinal studies, 15 found that greater religiousness predicted mild symptoms and faster remission at follow-up.
Smith and colleagues14 conducted a meta-analysis of 147 studies that involved nearly 100,000 subjects. The average inverse correlation between religious involvement and depression was 20.1, which increased to 0.15 in stressed populations. Religion has been found to enhance remission in patients with medical and psychiatric disease who have established depression.16,17 The vast majority of these studies have focused on Christianity; there is a lack of research on other religious groups. Some research indicates an increased prevalence of depression among Jews.18
Depression is important to treat not just because of the emotional distress but also because of the increased risk of suicide. In a systematic review that examined 68 studies, researchers looked for a relationship between religion and suicide.8 Among these, 57 studies reported fewer suicides or more negative attitudes toward suicide among the more religious. In a recent Canadian cross-sectional study, religious attendance was associated with decreased suicide attempts in the general population and in those with a mental illness, independent of the effects of social supports.19 Religious teachings may prevent suicide, but social support, comfort, and meaning derived from religious belief also are important.
More recent studies indicate that the relationship between religion and depression may be more complex than previously shown. All religious beliefs and variables are not necessarily related to better mental health. Factors such as denomination, race, sex, and types of religious coping may affect the relationship between religion or spirituality and depression.20,21 Negative religious coping (being angry with God, feeling let down), endorsing negative support from the religious community, and loss of faith correlate with higher depression scores.22 As Pargament and colleagues23(p521) state, “It is not enough to know that the individual prays, attends church, or watches religious television. Measures of religious coping should specify how the individual is making use of religion to understand and deal with stressors.”
Very few studies have specifically addressed the relationship between spirituality and depression. In some instances, spirituality (as opposed to religion) might be associated with higher rates of depression.24 On the other hand, there is a substantial negative association between spirituality and the prevalence of depressive illness, particularly in patients with cancer.25,26
Given the ubiquity of anxiety and religion, it is surprising how little research has been done with respect to the relationship between the two. The investigation of religious and spiritual issues in anxiety lags behind research on mental disorders such as depression and psychosis. Religious beliefs, practices, and coping may increase the prevalence of anxiety through the induction of guilt and fear. On the other hand, religious beliefs may provide solace to those who are fearful and anxious. Studies on anxiety and religion have yielded mixed and often contradictory results that may be attributed to a lack of standardized measures, poor sampling procedures, failure to control for threats to validity, limited assessment of anxiety, experimenter bias, and poor operationalization of religious constructs.27
Some studies have examined the relationships between religiosity and specific anxiety disorders such as obsessive-compulsive disorder and posttraumatic stress disorder (PTSD). Contrary to the views of Freud,28 who saw religion as a form of universal obsessional neurosis, the empirical evidence suggests that religion is associated with higher levels of obsessional personality traits but not with higher levels of obsessional symptoms. Religion may encourage people to be scrupulous, but not to an obsessional extent.29,30 Although religion has been found to positively affect the ability to cope with trauma and may deepen one’s religious experience, others have found that religion has little or negative effect on symptoms of PTSD.31
The relationships between generalized anxiety and religious involvement appear to be complex. In a comprehensive review of the relationship between religion and generalized anxiety in 7 clinical trials and 69 observational studies, Koenig and colleagues8 found that half of these studies demonstrated lower levels of anxiety among more religious people, 17 studies reported no association, 7 reported mixed results, and 10 suggested increased anxiety among the more religious.
A person’s strong religious beliefs may facilitate coping with existential issues whereas those who hold weaker beliefs or question their beliefs may demonstrate heightened anxiety.32 These contradictory findings may be accounted for by the fact that researchers have used diverse measures of religiosity. Other studies have focused on death anxiety. Research conducted in the United States and abroad points to denominational differences as well as to differential effects of religion and spirituality and emphasizes the complex relationships between religious and cultural factors.33 Studies on anxiety and religion to date have emphasized cognitive aspects of anxiety as opposed to the physiological aspects. Future studies should include physiological parameters.
A number of pathways have been discussed in the literature through which religion/spirituality influence depression/anxiety: increased social support; less drug abuse; and the importance of positive emotions, such as altruism, gratitude, and forgiveness in the lives of those who are religious. In addition, religion promotes a positive worldview, answers some of the why questions, promotes meaning, can discourage maladaptive coping, and promotes other-directedness.
Religion and coping in schizophrenia
Research in schizophrenia and religion has predominantly examined religious delusions and hallucinations with religious content. Recently, however, religion as a coping strategy and factor in recovery has been the subject of growing interest.34 Religious delusions have been associated with poorer outcomes, poorer adherence to treatment, and a more severe course of illness.35
A number of studies suggest that religious beliefs and practices can be a central feature in the recovery process and reconstruction of a functional sense of self in psychosis.36 On the other hand, Mohr and colleagues37 found that although religion instilled hope, purpose, and meaning in the lives of some persons with psychosis, for others, it induced spiritual despair. Patients also reported that religion lessened psychotic symptoms and the risk of suicide attempts, substance use, nonadherence to treatment, and social isolation.
Given that most religions actively discourage the use of substances that adversely affect the body and mind, it is unsurprising that studies generally indicate strongly negative associations between substance abuse and religious involvement. In a review of 134 studies that examined the relationships between religious involvement and substance abuse, 90% found less substance abuse among the more religious.8 These findings are corroborated by more recent national surveys and studies in alcohol and drug use in African Americans, Hispanic Americans, and Native Americans that similarly indicate negative associations between religious involvement and substance abuse.38-41
Negative psychological effects of religious involvement include excessive devotion to religious practice that can result in a family breakup. Differences in the level of religiosity between spouses can result in marital disharmony. Religion can promote rigid thinking, overdependence on laws and rules, an emphasis on guilt and sin, and disregard for personal individuality and autonomy. Excessive reliance on ritual and prayer may delay seeking psychiatric help and consequently worsen prognosis. At its most extreme, strict adherence to the ideology of a movement may precipitate suicide.
Religious issues are important in the assessment and treatment of patients, and therefore clinicians need to be open to the effect of religion on their patients’mental health. It is, however, important that clinicians do not overstep boundaries.
How then can clinicians enter into their patients’ spiritual lives? Blass42 and Lawrence and Duggal43 have emphasized the importance of teaching on spirituality in the psychiatric curriculum, with residents learning about the principles of spiritual assessment. There are a number of protocols about how to ask about spirituality, such as the HOPE questionnaire.44
After taking a detailed spiritual history, health professionals need to help patients clarify how their religious beliefs and practices influence the course of illness, rather than giving advice about religion. Whatever his or her religious background, the professional’s moral stance should be neutral, with no attempt to manipulate the patient’s beliefs. Clinicians must be aware of how their own religious beliefs affect the therapy process.45 Direct religious intervention, such as the use of prayer, remains controversial.46
A secular therapist who does not share the religious beliefs of the patient can still be effective as long as he is alert to the need for sensitivity to religious issues and the need to become educated about the religion’s beliefs and practices. At times, patients’ religious views may conflict with medical/psychotherapeutic treatment, and therapists must endeavor to understand the patient’s worldview and, if necessary, consult with clergy. It might be appropriate to involve members of the religious community to provide support and to facilitate rehabilitation.
Religion or spirituality may have therapeutic implications for mental health. Randomized trials indicate that religious interventions among religious patients enhance recovery from anxiety and depression.47,48 Psychoeducational groups that focus on spirituality can lead to greater understanding of problems, feelings, and spiritual aspects of life.49