Outing addiction

After Eugene O'Neill wrote the play "Long Day's Journey Into Night," he sealed it in wax and instructed his publisher not to publish it until 20 years after his death.

It was a play, he said, "of old sorrow, written in tears and blood." Over four-and-a-half hours, it portrays the fictional Tyrone family's disintegration at the hands of addiction, which mirrors what happened in O'Neill's own family. His mother was dependent on morphine, while he, his father and his two brothers struggled with alcoholism, the disease that eventually killed his older brother.

O'Neill's shame about his family's troubles ran so deep that he couldn't stand to see the play performed during his lifetime. He died in 1953, and was posthumously awarded the Pulitzer Prize for the play in 1957.

More than 50 years later, at APA's 2011 Annual Convention, a cast of actors and an audience of psychologists used the play to examine the issue of addiction-related stigma head on. As part of the Addiction Performance Project, a National Institute on Drug Abuse–sponsored continuing-education program, Oscar-nominated actor Debra Winger led a cast in a dramatic reading of part of the play. Through a series of these performances across the country, they hope to raise health-care professionals' awareness of addiction in their patients.

Winger, her husband Arliss Howard, and two other actors performed the play's third act, in which the Tyrone men confront Mary Tyrone, the matriarch, about her relapse into morphine use. In turn, Mary—played by Winger—rails against her husband's and sons' drinking.

Confronting secrecy

In a discussion following the performance, panelists noted how the scene portrays patterns of denial, blame, anger and bitterness that are typical in families affected by addiction. Certainly there are positive reinforcing effects of the drugs—pleasure and relaxation, for example—but there also negative reinforcing effects, said NIDA Acting Deputy Director David Shurtleff, PhD. "Family members take it not just to feel better but to escape pain, which then affects parts of the brain related to coping, emotional regulation and judgment. So this makes the family dysfunctional in relation to each other, and they escape into the drug even more to cope. It's a vicious cycle."

And addiction often goes untreated, he continued. Nearly 23 million Americans struggle with alcohol and drug problems, but only 2 million receive treatment.

Fellow panelist Kathleen Carroll, PhD, a psychiatry professor at the Yale University School of Medicine, echoed Shurtleff's comments. "The addiction keeps family members stuck and angry and unable to deal with each other," said Carroll, who is principal investigator of the New England Consortium of the NIDA Clinical Trials Network.

Battling stigma

Part of what fuels the stigma is people's reluctance to openly discuss addiction, said Carroll. "Why is it so hard to talk about addiction?" she said. "The family in this play was always talking around it ... I see the same patterns in my psychotherapy tapes—brushing over it, dancing around it."

In response, fellow panelist Carlo DiClemente, PhD, a psychology professor at the University of Maryland, Baltimore County, noted that facing addiction is uncomfortable and that, at times, watching the play made him want to leave the room. So how do psychologists stay in the room, cutting through the stigma and treating the addiction? DiClemente and other panelists and audience members suggested that they:

• Ask patients directly about past and present alcohol and drug use and about substance-abuse issues in their families.

• Draw patients out on addiction issues by asking follow-up questions.

• Choose less stigmatizing words, such as "person with addiction or alcohol problems," rather than addicts or alcoholics. "Stigma itself is a stigmatizing word," said one audience member.

• Work on empathizing with people with addiction problems and withholding judgment. "We psychologists are guilty of stigmatizing our own colleagues who have struggled with these disorders," said DiClemente.

• Understand that relapse is part of this disease, just like it is part of any chronic disease.

• Teach patients with addiction problems alternative coping and social-interaction strategies. "This is where psychology and cognitive-behavioral therapy can play a great role," said Shurtleff, "not just in treating the individual addict but in helping them come back into the family and society, helping to restructure and bring back that family unit."

Bridget Murray Law is a writer in Silver Spring, Md.

To learn more about the Addiction Performance Project's work to provide continuing education on addiction to health-care professionals, visit National Institute on Drug Abuse.