Here in the UK, one in five hospital admissions is the result of heavy drinking. Those who drink to the extent of needing medical assistance, as well as those who are caused problems by their own alcohol consumption, are known as harmful drinkers. This group is characterised not only by their high levels of alcohol consumption, but a surprisingly low level of problem recognition. Generally speaking, harmful drinkers are known for being resistant to seeing that they have an issue with drinking, often to avoid being labelled as an alcoholic, which comes with a huge amount of stigma. This phenomenon is part of what gave rise to the well-known phrase “I can stop anytime I want”.
However, this creates a significant barrier to treatment. “If there’s no problem, what’s there to fix?“
Researcher James Morris, alongside colleagues from London Southbank University and Northumbria University, believe that this kind of label avoidance is a prime target that psychologists can exploit to increase uptake of treatment in harmful drinkers. Their new study in Addictive Behaviors suggests that the solution may be as simple as reframing the issue.
People often think of drinking issues as binary — you either have one, and by extension are an alcoholic, or you don’t have any issues with alcohol consumption. This kind of binary disease model belief, however, is a simplistic approach. What’s more, the threat to identity posed by such a hard line in the sand leads to a lot of psychological resistance in heavy drinkers, who don’t wish to be saddled with the stigma of being labelled an alcoholic.
However, this isn’t the only way to think about diagnoses. As psychologists, we are familiar with the idea of many diagnoses lying somewhere on a continuum; similarly, alcohol use problems can be seen as lying on a spectrum of severity, as opposed to being divided by a stark cut-off line. Since continuum diagnoses less resemble being labelled, it’s possible that helping individuals hold such a view could lessen their label avoidance, and therefore resistance to problem recognition.
To test this, Morris and colleagues recruited 244 harmful drinkers who did not believe they had experience with addiction. Levels of problem recognition in participants were assessed via items from the Stage of Change Readiness and Treatment Eagerness Scale (SOCRATES), which is a questionnaire used to assess problem recognition, ambivalence, and progress towards recovery in those with alcohol consumption issues.
Participants were shown one of six framing messages pertaining to problem drinking. Two of these were based on the continuum model, and illustrated views that all levels of drinking cause some problems, and that there’s no stark cut-off point for having an issue with alcohol consumption. Another two illustrated the binary disease model, emphasising clear differences between those who experience problems with alcohol consumption and those who do not. Two further conditions were controls, which contained prose about governmental approach to alcohol consumption. In each of these categories, one condition contained stigmatising language regarding harmful drinkers, and the other did not.
Overall, the way in which alcohol problems were framed didn’t make a difference: participants who had seen messages based on the continuum or binary disease model showed similar levels of problem recognition. But when this message was considered alongside the presence or absence of stigmatising language, there was an effect. Those who had seen the message that framed alcohol problems in terms of a binary disease model and that included stigmatising language showed significantly lower levels of problem recognition than those who had seen the same framing, but with no stigmatising language. They also showed lower levels of problem recognition than those who had read that alcohol problems were on a continuum. There was no significant difference in problem recognition between those had seen stigmatising or non-stigmatising language within the continuum framing messages group.
The authors interpret the results as showing that alcoholic labelling avoidance was triggered in participants in the binary disease model plus stigmatising language group. They were motivated to deflect this threat to their identity, becoming extra resistant to acknowledging that their harmful drinking may be causing problems, in order to avoid the associated stigma.
This was not a pattern observed for those who read about harmful drinking as a continuum, which suggests that this may be a more effective approach for encouraging those who drink excessively to recognise the impacts it may have on their lives, and subsequently access treatment. By avoiding that hard line in the sand of labelling someone an alcoholic, people are likely to feel less threat to their identity by acknowledging issues they may be having with alcohol consumption, and thus more willing to make changes.
As such, the authors believe that public health messaging embracing a continuum approach which minimises stigmatising language would be most effective in targeting harmful drinkers, and represents a low cost method of improving outcomes in this group.
Emma L. Barratt (@E_Barratt) is a staff writer at BPS Research Digest