Compassion When Treating Substance Users

by Academy of Clinical Excellence on July 29, 2011

“You encourage people by seeing good in them” – Nelson Mandela[1]

I know that science doesn’t always inform public policy.If so, high schoolers would begin their day later than elementary school children; cursive writing would be taught before print; syringe exchange programs would be the rule instead of the exception; preventive health care would be a right instead of a privilege, etc.So why was I so surprised when I saw billboards popping up along Baltimore’s highways proclaiming “DUI Is for Losers”?(Don’t believe me, see images of the entire campaign for yourself here

Now, don’t get me wrong I’m against drunk driving as much as the next person.No, that’s a lie.I’m against it more than the next person since I’ve seen firsthand the destruction of life and property it’s wrought.Firsthand.And I treat substance-dependent men and women, many of whom have been charged with DUIs at some time in their life.I’ve heard their compelling and, often, tragic stories of loss.I know that driving drunk can cause unimaginable heartache and irreversible consequences.

But ad campaigns that focus their efforts on stigmatizing individuals with substance use disorders rather than the behaviors themselves aren’t productive.I’ve seen several patients who have accidentally killed their loved ones while intoxicated, and been incarcerated for their crimes, but who nevertheless continue to drive drunk.If that degree of loss and consequence doesn’t motivate someone to change, no loss or consequence will.

All parents have heard the adage: “Criticize the behavior, not the child.”The same holds true for clinicians treating individuals with substance use disorders.Behavioral science teaches us to stigmatize the behavior we want to change, but to build up and motivate the individual to change.[2]I assure you that people with substance use disorders have more than enough self-loathing; they don’t need any more from us.In fact, an individual’s negative self attitude and hopelessness only sustains substance use.So name-calling, which is the basis of the “Loser” campaign above, and focusing on “loss and consequences” ( is a misguided strategy to promote change and will be unproductive at best and counterproductive at worst.

What works to motivate change?Helping individuals find positive, rewarding, self-esteem boosting behaviors that can compete with the substance use.Positive “reinforcements” like education, employment, exercise, substance-free recreational activities, and the realization that theirs is a life worth living.We can play a role in this realization and, guess what, it’s not by name-calling and shaming. It’s by recognizing that NOT having a substance use disorder is an unearned privilege and showing compassion towards those who do.

[2] Smedslund G, Berg RC, Hammerstrøm KT, Steiro A, Leiknes KA, Dahl HM, Karlsen K.Cochrane Database Syst Rev. 2011 May 11

Margaret S. Chisolm, MD

Assistant Professor

Department of Psychiatry and Behavioral Sciences

Johns Hopkins University School of Medicine

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{ 4 comments… read them below or add one }


Anne Marie August 4, 2011 at 7:40 am

Hello,I can see where you are coming from but are most drink driving offences convicted by people with addiction? Or are people with addictions responsible for most drink-driving related deaths?My guess is that they are not and instead it is the wider population who are responsible. Those convicted of drink-driving are stigmatised because they are now seen to have broken a social norm which has been established in society in the past few decades. I was looking online to see how UK adverts compared and I came across this article about a retired local orthopaedic surgeon. is no suggestion that he has a substance-misuse disorder. He's in a powerful position and he still thought that diving over the limit was a risk worth taking. To me those are the people that these campaigns are being aimed at.But I don't know the facts and figures. If it is true that most offences are committed by those with addictions then perhaps other approaches are justified.Anne Marie

Margaret Chisolm July 31, 2011 at 8:50 am

I hear what you're saying. I felt similarly about individuals w/ drug problems, especially parents of young children. It wasn't until I started working w/ drug-dependent pregnant women that I started to see things differently. The majority of my patients are ashamed and guilty over their use and are desperate to find a way to stop. They've taught me a lot about what helps them change their behavior and what makes things worse! It's a rewarding place to work as I've seen so many women stop using for the good of their children.

katieinwonderlandx July 31, 2011 at 8:30 am

I found this very thought provoking. Growing up with substance abusing parents, and in rougher areas of Scotland, i have little sympathy, and very little compassion for those who abuse alcohol and drugs, particularly those raising children. I did find this an interesting read that questions my own opinions. Difficult to apply this in a general sense though. Individual situations may not allow for such understanding.

Margaret Chisolm July 29, 2011 at 6:39 pm

oops; last line should read: "It’s by recognizing that NOT having a substance use disorder is an unearned privilege and showing compassion towards those who do."Hope that makes more sense now.

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