Disrupting 'valid denial' in harmful drinkers: the potential ...
Continuum beliefs increase problem recognition among harmful drinkers without addiction experience James Morris, PhD candidate, London South Bank University Overview Harmful drinkers are an overlooked population: Do not access treatment Unlikely to respond to brief interventions Characterised by denial i.e. low problem recognition Limited research exploring ways to increase problem recognition as a first step to behaviour change One opportunity may be via promoting continuum beliefs My PhD studies sought to explore this
Harmful drinkers? Defined as consuming alcohol at levels which are already causing negative psychological or physiological effects (e.g. ICD-11)  In the UK, harmful drinkers also defined as either: 35+ (women) or 50+ units (men) per week Score 16+ on the AUDIT* Distinguished from dependent drinkers (i.e.subthreshold) i.e. score low on dependence measures (SADQ/LDQ)** But outnumber dependent drinkers by more than 2:1
e.g. in England 1.3 million harmful drinkers versus 600k dependent** *Alcohol Use Disorders Identification Test **Based on a moderate/severe dependence criteria (Pryce et al. 2017)  Stepped care model: missing steps? The treatment system - % with mild dependence receiving treatment estimated at 1.13% (NICE)  NICE alcohol guidance: CG115 (2011) But Harmful drinkers have low problem recognition:
Do not describe their drinking as problematic  or recognise associated health problems  Underestimate their drinking more than any other group  Drinking often an important an part of their identity [4,7] Rarely engage in treatment  Point to others as problem drinkers e.g alcoholics [9, 10, 11, 12] Problem recognition or denial?
Denial may be an common lay term, but denial is complex, poorly defined etc.  Valid reasons for low problem recognition may include: Still meeting responsibilities  Drinking pros seen as > cons  Normative misperception  Fear of stigma/labelling [8, 15, 16] Binary thinking: lack of an available language/framework to understand their drinking..? [17, 18] The Nile: Not just a river in Egypt? Binary thinking..?
Human tendency to categorise things i.e. to help simplify and makes sense of the world  & ease cognitive load  The alcoholism false binary reflects lack of an adequate framework for harmful drinkers to assess their drinking [18, 21] E.g. Am I an alcoholic?  YES/NO?
For every complex problem there is an answer that is clear, simple, and wrong. H. L. Mencken Navigating binary frames? My names Adrian Chiles, and Im not an alcoholic at least, I dont think I am...? Adrian Chiles, Drinkers Like Me 2018 How else can we frame alcohol problems to avoid the false binary?
The potential of continuum beliefs? All drinking and problems can vary in severity I.e. anyone who drinks can experience alcohol problems DSM-V shift to AUDs by severity (rather than abuse vs dependence distinction) Promoting continuum beliefs has been positive in the context of mental health help-seeking and stigma  My PhD study 1 sought to test continuum vs binary beliefs amongst harmful drinkers..
Have a word version of the AUDIT-C Study 1 design Online experimental study recruitment via social media (n=579) 3 conditions (IV): Control Continuum Binary Disease Model (BDM)
Manipulation check adapted from the Addiction Belief Scale Main Dependent Variable of Problem Recognition Moderator variable of addiction experience Primary hypotheses: 1. Continuum beliefs would increase problem recognition amongst harmful drinkers without addiction experience 2. Binary disease model beliefs would decrease problem recognition amongst harmful drinkers without addiction experience 3. No effect of condition on non-harmful drinkers
or those with addiction experience Study 1 design Conditions used a first person audiovisual vignette based on narrative persuasion techniques Hi, Im Dan. Alcohol can cause some people problems so I wanted to talk to you about mine briefly Continuum extract: My drinking had become a problem but Im not so different from most people. There is no clear line between my experience and those who dont have alcohol issues anyone could develop a problem with alcohol if they drink heavily... Manipulation check confirmed predicted differences in beliefs
Difference between Conditions on the continuum (F (2, 594) 8.91, p<.001, p2= .029) and BDM (p2= .029) and BDM (F = (2, 594) 15.62, p<.001, p2= .029) and BDM (p2= .050) Study 1 results (accepted) Main effects: Harmful drinkers with no self-identified addiction experience had higher problem recognition in the continuum condition versus control (p=.007) and binary (p<.001) conditions But no significant difference between binary and control As predicted, no effect of
condition on non-harmful drinkers or those with Continuum belief mechanisms? Alcohol and addiction problems are highly stigmatised; people want to avoid the negative consequences of belonging to the stigmatised out group [8,10,11,12, 23] Thus protection from self-stigma may be a key motivation to other e.g: People state not wanting treatment because it will confirm their status as an alcoholic and therefore
become a target for prejudice and discrimination  Or continuum beliefs simply provide a more logical framework for self-evaluation Limitations & next steps Harmful drinkers are a heterogeneous group with a range of drinking motives, behaviours and beliefs - including about addiction Manipulations included different recovery implications i.e. continuum vignette included behaviour change of drinking reduction Vs abstinence in the binary group Continuum representation also has limitations e.g. doesnt reflect abstinence (or periods of) and says drinking problems which may still be considered a binary framework What mechanisms may underlie belief effects Implications for individual interventions or policy measures?
Conclusions Whilst beliefs about alcohol problems are not purely binary or continuous, shifting beliefs towards a continuum model may have significant benefits for: Behaviour change / help-seeking amongst harmful drinkers Reducing the stigma of alcohol problems at large False perceptions of non-problem drinking as riskfree Support for effective population policy measures Researchers, policy-makers and individuals can help by: Retiring binary/stigmatising terms like alcoholism Promoting a diverse range of narratives about alcohol use, problems and routes to change/recovery Contact & thanks
[email protected] Twitter @jamesmorris24 With thanks to Alcohol Change UK and LSBU for support Supervisors Prof Tony Moss, Prof Ian Albery, Prof Nick Heather References 1. NICE. (2011). Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence [CG115]. The British Psychological Society and The Royal College of Psychiatrists. Retrieved from https://www.nice.org.uk/guidance/cg115/evidence 2. Pryce, R., Buykx, P., Gray, L., Stone, T., Drummond, C., & Brennan, A. (2017). Estimates of Alcohol Dependence in England based on APMS 2014, including Estimates of Children Living in a Household with an Adult with Alcohol Dependence Supplementary tables, (April). Retrieved from http://www.nta.nhs.uk/uploads/alcohol-estimates-supplementary-tables.xls 3. NICE. (2011a). Alcohol-use disorders: diagnosis, assessment and management of harmful
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