Why Are We So Afraid of Choice When It Comes to Substance Use Problems?

May 5, 2015

why-are-we-so-afraid2Stigma and judgment continue to persist when it comes to substance problems and it’s time the conversation changed in this country from moralistic judgment and pessimism to compassion and understanding. For a variety of complicated reasons, our culture does not have a track record of treating people with substance problems and the families around them with the kindness they deserve. Thankfully, we feel hopeful about the future as science has given us reason to change.

In order for us to change the conversation however, we have to continue to confront the stigma and persistent moralistic view of the problem. We have to challenge those who believe that people who develop problems with substances are diseased, weak-willed, self-centered, less than, and essentially to blame for their choices. We have to question those who use derogatory vocabulary (entitled, selfish, lazy) or descriptions of character flaws to describe people with substance use problems. How can we expect people who struggle to step forward and ask for help when they feel misunderstood at best and possibly even denigrated and shamed? Families resist seeking help for many of the same reasons, as they expect to be told they also have a disease and the only cure is to detach or distance and use tough love, all of which are counter-intuitive to the connection they want to maintain with their loved one. In the end, the shame substance users and their families feel results in isolation, with people hiding truths from themselves and others, and in the process being blocked from seeing pathways of hope and possibility with treatment.

The Power of Choice:
There is also an enormous gap between what consumers think their treatment options are and what science has actually found to be helpful. Most consumers know about 12-step support and rehab but know little about motivational interviewing, cognitive behavior therapy (CBT), Community Reinforcement and Family Training (CRAFT), and medications, all of which have clear rates of success in both getting people into treatment and achieving successful outcomes.

What is causing this gap between what we know thanks to science and what consumers think their options are? Again, the effects of stigma and the moralistic view of the problem play big roles. For example, negative assumptions can be seen in many people’s beliefs or concerns about using medication to treat substance use disorders. There are several medications that help substance users get back on track and lower risk of overdose, but many are viewed as “crutches,” as if using a crutch when one is injured is somehow weak-willed. Buprenorphine, Methadone, Disulfiram, Naltrexone, and Vivitrol are all medications that when combined with therapy and/or family support save lives. Period. They are of course not magic bullets, but they decrease death rates and improve the course of recovery for many. Unfortunately, there continues to be a persistent belief that using medications means one is not in “real recovery” because some of them are replacement or “maintenance” medications (buprenorphine, methadone), and therefore keeping a person dependent on a substance. And for some reason, it seems that many people are more invested in talking about the ways these medications are problematic than talking about the number of lives they are saving. If staying on a medication can save a person’s life, is that not a reason to consider it? Why not at least present it as an option and work with the person to see if it would be helpful to their change process.

Individual variation matters, individual circumstances matter. Different treatment options and community supports work for different people, often at different times. Instead of talking about moral character flaws and lack of willpower to make good choices, we need to encourage the media and our culture at large to read up on all science has to offer us when it comes to understanding substance use problems. We can help more people, earlier in the development of the problem (and therefore may even prevent problems!) if we encourage people to know their options and advocate for themselves and their families. We also need to resist the urge to get into fear-based, black and white discussions about some of the very important options that are available to substance users. It may well be that making a choice to be on a maintenance medication can change the course of a person’s change process in a positive way. We need to wonder why we continue to send the message that there is an inherent “weakness” to making that choice.

Let’s instead have the goal of helping substance users and their families become highly educated consumers who feel like they can ask for what they need and have a treatment system that is sophisticated and diverse enough to provide it. Get involved, be a part of changing the conversation and advocating choice when it comes to treating substance use problems. Research and clinical experience has shown time and again that different supports and treatment options…work at different times…for different reasons.

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