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Barriers to treatment: Why alcohol and drug abusers delay or

never seek treatment

Article  in  Addictive Behaviors · May 1993

DOI: 10.1016/0306-4603(93)90036-9 · Source: PubMed

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Addictive Behmiors, Vol. 18, pp. 341-353. 1993 0306-4603193 $6.00 + .OO
Printed in the USA. All rights reserved. Copyright 0 1993 Pergamon Press Ltd.

BARRIERS TO TREATMENT: WHY ALCOHOL AND DRUG

ABUSERS DELAY OR NEVER SEEK TREATMENT

JOHN A. CUNNINGHAM,* LINDA C. SOBELL.*+: MARK B. SOBELL,*:i:

SANGEETA AGRAWAL,? and TONY TONEATTO’F!:
*Department of Psychology, University of Toronto
tAddiction Research Foundation
j;Department of Behavioural Science. Faculty of Medicine. University of Toronto

Abstract - Reasons for delaying or not seeking treatment were compared between outpa-
tient alcohol and drug abusers. and between alcohol abusers who had either resolved their
problem without treatment. were currently not resolved, or were in an outpatient treatment
program. Outpatient alcohol and drug abusers exhibited few differences in their endorsed
reasons for delaying seeking treatment. There were. however. several differences between
resolved and nonresolved alcohol abusers who had never sought treatment and alcohol
abusers in treatment (e.g., endorsing items such as “wanted to handle problem on own.”
“didn’t think I had a problem”). Such differences may explain why some problem drinkers
do not seek treatment. Treatment implications of these findings are discussed.

The vast majority of alcohol abusers do not enter treatment. The estimated ratio of
untreated to treated individuals ranges from 3 : I to 13 : 1 (reviewed in Sobell. Sobell,
& Toneatto, 1992). To successfully attract such individuals to treatment, it is impor-
tant to understand their reasons for not seeking treatment.
In a general population survey, respondents who had ever had an alcohol problem
reported several reasons for not seeking treatment promptly: 84% did not think their
problem was serious enough, 96% thought they could handle it on their own. and
56% said they did not want to admit that they needed help (Hingson, Mangione,
Meyers, & Scotch, 1982). Alcohol abusers in treatment or who sought advice about
their drinking have also reported delaying seeking treatment because they felt their
drinking was not a problem or was not serious enough to warrant attention (Miller.
Sovereign, & Krege, 1988; Thorn, 1986). The stigma associated with the label “alco-
holism” or with admitting to being an alcoholic has been another reason problem
drinkers gave for not wanting to enter treatment (Roizen, 1977; Tuchfeld, 1976).
Heroin abusers who resolved their problem without treatment have reported rea-
sons similar to alcohol abusers for not seeking treatment (Biernacki. 1986). Within
exclusive categories, 35% reported they could handle their problem on their own,
19% did not believe treatment would help, and 14% feared the stigma of treatment.
In addition to the reasons endorsed above, Rounsaville and Kleber (1985) found that
20% of their opiate addicts did not seek treatment because they liked to be high and
did not want to give up the intoxication experience. Finally, in a recent study of
heroin abusers who had recovered without treatment, 30% stated that a lack of

The views expressed in this paper are those of the authors and do not necessarily reflect those of the
Addiction Research Foundation. The research presented in this paper was supported. in part. by a grant
#AA08593-OIAI from the National Institute on Alcohol Abuse and Alcoholism. Portions of this paper
were presented at the 25th Annual Meeting of the Association for the Advancement of Behavior Therapy.
New York City, November 1991.
Requests for reprints should be sent to John Cunningham, Addiction Research Foundation, 33 Russell
Street. Toronto, Ontario, M5.S 2SI Canada.

347
34x J.A. CUNNINGHAM etal

information about treatment availability acted as a barrier for not seeking treatment
(Klingemann, 1991).
The present study included outpatient alcohol and drug abusers currently in treat-
ment and compared them to alcohol abusers who had resolved their drinking prob-
lems without treatment and to alcohol abusers who were not in treatment and had
not resolved their problems. This study addressed two qu@stions: (a) Are the barriers
reported by alcohol abusers who eventually seek treatment different from those who
have not sought treatment‘? and (b) Do alcohol and drug abusers give different
reasons for delaying seeking treatment‘?

M E T H 0 11

The study involved three groups of subjects: (a) Self-change alcohol abusers (II =
92) who had resolved a drinking problem without treatment (abstinent and nonabsti-
nent resolutions) and had a minimum recovery period of 3 years: (b) Untreated,
nonresolved alcohol abusers (n = 62) with a current problem when interviewed. no
prior treatment history, and a drinking problem 25 years: and (c) Alcohol and drug
abusers (H = 192) currently in outpatient treatment (Addiction Research Foundation,
Toronto), but who reported that they did not seek treatment immediately upon
recognition of their problem. Outpatient clients volunteered to fill out a question-
naire at intake assessment. Measures of alcohol and drug use severity were not
available for these clients. Self-change and untreated, nonresolved alcohol abusers
responded to newspaper or radio advertisements and answered questions within a
structured interview. Information regarding alcohol dependence in these samples
has been reported elsewhere (Sobell et al.. 1992).
Based on the literature (Tuchfeld, 1976, 1981), subjects were asked to indicate
whether any of five possible factors had affected their delaying or not seeking formal
help or treatment: embarrassment/pride, unable to share problems, stigma, negative
attitude towards treatment, and monetary costs. Additional reasons were also solic-
ited from the subjects. For each reason endorsed, subjects indicated on a 5 point
scale how much the reason had affected their decision not to seek treatment (I = not
at all affected/influenced, 3 = somewhat affected/influenced, 5 = very much af-
fected/influenced). The 5 reasons and subjects’ additional responses were coded by
three judges into I I categories used in previous studies (Sobell et al., 1992: Tuchfeld.
1976). Discrepancies were resolved through discussion.

RESULTS
Two sets of analyses were conducted. The first analysis compared outpatients
with a primary alcohol problem to outpatients with a primary drug problem. The
second analysis compared the responses of three different groups of alcohol abusers:
outpatients, self-changers (no treatment), and untreated, nonresolved.

Questionnaires were given to 351 patients at an outpatient clinic at the Addiction

Research Foundation (Toronto, Canada). Seventy-two subjects were excluded be-
cause they reported having sought treatment as soon as possible after recognizing a
problem. Demographic characteristics for subjects who delayed treatment versus
those who sought treatment upon recognition of a problem were not significantly
 Barriers to treatment 349

different (p > .05). Questionnaires from 85 subjects were also discarded because
they were filled out improperly (e.g., incomplete, listed several primary drug prob-
lems), and two were discarded because cigarettes were the primary drug problem.
The final sample consisted of 192 subjects.
Subjects were grouped by their self-reported primary drug problem: 127 alcohol
abusers and 65 other drug abusers (cocaine, n = 41; cannabis, II = 21; other, II = 3).
No information was available regarding other substances used by these subjects. The
first two columns of Table 1 display the demographic characteristics for the outpa-
tient alcohol and drug abusers. Outpatient alcohol abusers were older than outpatient
drug abusers [t(l90) = 4.06, p < .OOl], had more education [x? = 5.8, p < .02. ulf’=
11, and reported a longer problem history [r(190) = 4.62, p < .OOl].
Table 2 displays the reasons given by the outpatient subjects for delaying or not
seeking treatment. Chi-square tests and two-tailed Fisher’s exact tests (for those
variables with >20% of cells with expected frequencies ~5) found no significant
differences (p > .05) between alcohol abusers and drug abusers for the frequency of
endorsement of any of the reasons for not seeking or delaying treatment. There were

Table I. Demographic characteristics

Drug ODA vs. OAA vs. RAA

abusers Alcohol abusers OAA,’ v\. UAAh

Resolved
without Untreated
Outpatient Outpatient treatment nonresolved
Variable (/I = 65) (12 = 127) (n = 92) (n = 62) P P

% Male’ 78.5 80.3 Xl.5 74.2

32.6 (6.3) 37.9 (9.7) 43.3 (10.5) 38.8 ( 1I .6) *+J xx’l1.e
Mean (SD) Age
%’ with some
postsecondary
35.9 54.4 19.6 29.0 * *x
education‘
Length of primary
drug problem:’
54.9 21.6 13.0 3.2 *r *
O-5 years (70)
6-10 years (%/r) 19.6 20.7 32.6 37. I
> IO years (%) 25.5 57.8 54.3 59.7
First time sought
formal help/
treatment
(% Yes) 63.1 54.0
Referral source

El); 64.1 65.9

Other 21.9 21.4
Legal 14. I 12.7

,‘ODA vs. OAA = Outpatient Drug Abuse vs. Alcohol Abuse Comparisons.
bOAA vs. RAA vs. UAA = Outpatient Alcohol Abusers vs. Resolved Alcohol Abusers (no treatment)
vs. Untreated Alcohol Abusers.
cChi-square tests.
+tests (2-tailed).
cOne-way ANOVA.
‘Resolved without treatment: age at resolution: Nonresolved: age at random target date: Outpatient:
age at treatment entry.
Scheffe post hoc comparisons: Resolved without treatment group differed significantly (p < .OS) from
nonresolved and outpatient groups.
*p < .Ol; **p < ,001.
 350 J. A. CUNNINGHAM et al

Table 2. Percentage and mean rating5 of outpatient alcohol and drug abuser\ endorsing factory that
delayed their \eeking treatment

Mean (.\I)) rating of how much

the reason affected 01
influenced decision lo dela\i
5 Endorsing I-cawn \eeking treatment“

Reason Alcohol abuser\ Drug abuwra Alcohol ahu\er\ Druc! abuser-\

Embarrassment/pride 42.5 i.h(O.C)I i.S( I .O)

No problem perceived/no help
needed/no need to \eek help 23.6 4.3(0.X)’ 4.4(0.7)”
Unable to \har-e problem\ 54.3 3.7(0.9Y i.c)( I .O)’
Stigma 54.3 i.7CO.9) 3.4 I .ot
Wanted to handle problem on
own 17.3 9.2 3.7(O.S) ?.X(O.SY”
Negative attitude toward
treatment 36.2 40.0 3.5CO.9) 3.4to.91
Monetary cwts involved IX.9 9.2 3.h(l.l) 1.3 I .6)
Ignorance of treatment avail-
abilitv’ 2.4 0.0 5.0(0.0)~ na
Harrier; to treatment’ 5.5 4.6 1.O(O.h) 3.5(0.7)
En.joyment of drinking’ 5.5 0.0 -!.O(O.O)’ IlZl'
Keawn\ not determinable 11.x 6.2 4.6(0.) I.i(O.6)

,‘Chi-square teat\.
“/-te\ts I?-tailed).
LX mis\ing.
“3 mi\Gng.
cI mic\ing.
‘2 mi\\ing.
$7 missing.
h/J ‘. .05.
‘Since ’ 20% of cell\ had expected frequcnciej -:5. t\\o-tailed Fisher’\ exact te\ts were employed
Ina = Not applicable. no subjects endorsed thi5 reawn.

also no significant differences in the overall number of categories endorsed for alco-
hol versus other drug abusers (p > .OS). Finally, for all outpatients who endorsed
“wanted to handle problem on own” as a reason for delaying seeking treatment,
alcohol abusers rated it as more influential than drug abusers lt( 17) = 4.65. p < .05].

Demographic characteristics for the three groups of alcohol abusers are shown in
Table I. The self-change group was older than either the outpatient or untreated.
nonresolved group [k-(2.278) = 7.6, p < ,001: Sheffe post hoc test, p < ,051. The
outpatient group had more education [x’ = 30.3, p < .OOl, df’ = 2J and a shorter
history of alcohol problems than the self-change and untreated, nonresolved groups
[x’ = 16.7, p < .Ol, c/f = 41. This latter finding is probably a procedural artifact as
subjects in the self-change group had resolved their alcohol problem and the un-
treated. nonresolved subjects had to have had a problem for at least 5 years.
Table 3 displays reasons for not seeking or delaying treatment for the three differ-
ent groups of alcohol abusers. Using 2 x 3 chi-square analyses (for those variables
with ~20% of cells with expected frequencies < 5). several significant differences
were found in the proportion of each group endorsing the various reasons for not
seeking treatment. On inspection of the observed frequencies and standardized re-
 Table 3. Percentage and mean ratings of alcohol abusers endorsing factors that affected their seeking or delaying seeking treatment

Mean (SD) rating of how much the reason affected or

c/r Endorsing reason,’ influenced decision to delay or not seek treatment”

Resolved Outpatients Resolved Outpatients

without Untreated in without Untreated in
Reason treatment nonresolved treatment p value lreatment nonresolved treatment p value

Embarrassment/pride 41.3 Xi.5 42.5 4.ltl.o) 3.Y(l.l) 3.6CO.Y) p -c .OY

No problem perceived/no help needed/no
need to seek help 43.5 48.4 23.6 p < ,001 4.4t I. I)‘] 4.4( I .O) 4.3(0.X)’
Unable to share problems 46.7 38.7 54.3 4.1(0.9) 3.9CO.9) 3.7(O.Y)’
Stigma 33.7 48.4 54.3 p < .Ol 4.2( I .O) 4.3fO.Y) 3.7Kt.9) /J cc .Ol’
Wanted to handle problem on own 40.2 33.9 17.3 p < ,001 4.5( I .O)h 4.6( I .O) 4.7fO.5)
Negative attitude toward treatment 30.4 19.4 36.2 4.4fO.Y) 4.2( I .O) 3.X0.9) /I < .OOlL
Monetary costs involved 4.3 19.4 18.9 p <: .Ol 4.3( I .O) 4.2(0.8) 3.6(l.l)
:$
- Ignorance of treatment availability 6.5 11.3 2.4 /I < .O5 3.8(1.2) 4.7(0.8) 5.0(0.0)
Barriers to treatment’ 2.2 6.5 5.5 4.0( I .4) 4.0( I.21 4.0(0.6)(
Enjoyment of drinking] 0.0 0.0 5.5 nai na’ 4.OfO.O)’
Reasons not determinable 0.0 4.x II.8 p < .Ol naL 4.0( I .tl) 4.6tO.S)

“Chi-square test.
hOne-way ANOVA.
Sheffe post hoc comparison\: Resolved without treatment group differed Ggnificantly from the outpatient group (p <: .OZt.
d12 missing.
‘8 missing.
‘I missing.
Gheffe post hoc comparison\: Outpatient group differed significantly from the nonresolved and re$olved without treatment groups
h4 missing.
‘7 missing.
Chi-square not determinable as ~20% of cells had expected frequencies of ~5.
Lna = Not applicable, no subject endorsed this reason.
‘2 mis\ing.
352 .I.
A.CUNNINGHAM eta1

siduals it appears that: (a) the self-change and untreated, nonresolved subjects en-
dorsed “no problem perceived/no help needed” and “wanted to handle problem on
own” as reasons for not seeking treatment significantly more often than the outpa-
tient alcohol abusers [x2 = 14.9, p < .OOl. c(f’= 2 and x2 = 14.9, /I < .OOl. & = 2.
respectively]: (b) outpatient and untreated, nonresolvcd subjects endorsed “mone-
tary costs” significantly more often than the self-change group Lx’ = I I .O, p < .Ol,
df’= 31: Cc) outpatient subjects endorsed “stigma” significantly more often than the
self-change group [x’ = 9.3, p < .Ol, df‘= 31: and (d) untreated, nonresolved alcohol
abusers endorsed “ignorance of treatment availability” more often than the outpa-
tient subjects [x2 = 6.36, 1) < .05, cl/‘= 21. Finally, when all reasons for not seeking
treatment were summed for each subject. there were no significant difference in the
number of categories endorsed across the three groups (p > .05).
For those who endorsed each reason. self-change sub.jccts rated “emharrassment~
pride” and “negative attitude towards treatment” as more inHuential reasons for not
seeking treatment compared to the outpatient subjects [F(2.124) 7 3.6, 11 i .05) and
F(2.81) = X.4. p < .OOl. respectively: Sheff@ post hoc tests. p sc ,051. Self-change and
untreated, nonrcaolved sub.jccts rated “stigma” as a more influential reason for not
seeking treatment than did the outpatient subjects 1kI2.127) = 5.9, 17 /: .Ol: Shcff6
post hoc tcsfs. p < ,051.

1) I s c u s s I 0 N

Barriers to treatment reported by alcohol abusers who eventually 4ought treatment

were different from those who did not seek treatment. Compared to alcohol abusers
in treatment. those who had recovered without treatment or who still had active
problems and were not in treatment were more likely to report they had not cntcrcd
treatment either because they did not perceive their drinking as a problem or because
they wanted to handle it on their own. The belief that their drinking N’;IS not a
concern suggests that it is important to increase problem drinker’s awareness of
hazardous levels of consumption and of the risks associated with their consumption
as a means of motivating them to seek treatment (Miller & Rollinick. I991 : Millet- et
al.. 198X). Alcohol abusers’ desire to handle their problem on their own may reflect
negative factors associated with treatment or the importance of self-determination
for these subjects. Compared to outpatients, self-change and nonresolved. untreated
alcohol abusers rated the stigma attached to being called an alcoholic as being more
influential in their decision not to seek treatment. Self-change subjects also rated
embarrassment or pride and a negative attitude toward\ trcatmcnt as more important
reasons for not seeking treatment than the outpatients. Collectively, these ratings
suggest that current treatment is stigmatizing and that some alcohol Ltbusers believe
that seeking treatment would reflect negatively on them. Alternatively. it might be
that once clients enter treatment, their negative attitudes towards treatment are
reduced. While a prospective study is needed to confirm this explanation, the stigma
of being labelled an alcoholic was endorsed by many subjects in all groups, indicating
that this problem is substantial and cuts across different populations of alcohol
abusers.
Outpatient alcohol and other drug abusers gave surprisingly similar reasons for
delaying seeking treatment. Only one significant difference was observed between
these subjects. For those outpatients who endorsed “wanted to handle problem on
own” as a reason for delaying seeking treatment, alcohol abuser\ rated it as more
influential than drug abusers.
 Barriers to treatment 353

This study is limited by subject selection factors. Subjects who sought or did not
seek treatment could differ in unknown ways (as well as in demographic characteris-
tics) which could be responsible for the differences observed between these groups.
Also, the use of multiple statistical comparisons increases the probability of signifi-
cant results appearing just by chance. Nevertheless, the findings from this study and
others (Hingson et al., 1982; Miller et al., 1988; Thorn, 1986) convincingly demon-
strate that there is stigma associated with seeking treatment. These barriers must be
addressed if we want to encourage the greater population of untreated alcohol and
drug abusers to seek treatment. Some barriers might be reduced by a change in
public perceptions of the nature of drug problems, the role of treatment, or by how
and where treatment is offered. Traditional approaches to the treatment of alcohol
problems have been hypothesized to deter problem drinkers (i.e., those with less
severe problems) from seeking treatment (Sobell & Sobell, 1993). Alternative ser-
vices tailored to problem drinkers are available (Heather, 1990: Miller & Sovereign,
1989; Sobell & Sobell, in press) and their ability to attract more clients than tradi-
tional treatment programs could be empirically tested.

REFERENCES

Heather. N. (1990). Brief intervention strategies. In R. K. Hester B W. R. Miller (Eds.). Htr,tdhooX c:f
crl~~oholism tl’e~tm~‘lrt trppuocrc~/re.\: Effec,tiuc rr//etxcrtiuc~.c (pp. 93-l 16). New York: Pergamon Press.
Hingson. R., Mangione, T., Meyers, A.. & Scotch, N. (1982). Seeking help for drinking problems: A
study in the Boston metropolitan area. Jol~mrrl ctfSt&ic,.s on AIwhol. 43, 273-288.
Klingemann, H. K.-H. (1991). The motivation for change from problem alcohol and heroin use. B~ifi.\h
Jorrr-nul of Addic,tion. 86, 727-744.
Miller. W. R.. & Rollinick, S. (1991). Motiutrtionul interuira,irlg: Prc~ptrring pcwpleto c~htrngrddic~tiw
hehuuior. New York: Guilford Press.
Miller, W. R., & Sovereign, R. G. (1989). The check-up: A model for early intervention in addictive
behaviors. In T. Loberg. W. R. Miller. P. E. Nathan. & G. A. Marlatt (Eds.). Addic,tiuc hchcruior.~
preuenrion and rur/y intc~ruc~ntion (pp. 219-231). Amsterdam: Swets & Zeitlinger.
Miller. W. R., Sovereign, R. G.. & Krege, B. (1988). Motivational interviewing with problem drinkers: II.
The drinker’s check-up as a preventive intervention. Brhcruiorrrtrl P.s?(,hot/re,crp?. 16, 251-268.
Roizen, R. (1977). Burricrs to rr/coho/i.sm treutment. Berkeley. CA: Alcohol Research Group.
Rounsaville. B. .I.. & Kleber, H. D. (198s). Untreated opiates addicts: How do they differ from those
seeking treatment? Arc,hiucs ofGcnrrcr/ Psychiutry. 42. 1072-1077.
Sobell, L. C., Sobell, M. B., & Toneatto. T. (1992). Recovery from alcohol problems vvithout treatment.
In N. Heather, W. R. Miller, & J. Greeley (Eds.), Sc~Ukorztro/ crudtile rrddictiuc hchc~uiorrrs (pp. 198-
242). New York: Maxwell MacMillan.
Sobell. M. B.. & Sobell. L. C. tin press). Guided sc!f-mt/nrrR~~ncrIt trcc/tmvnt of’ct/c~o/ro/ prohlemc. New
York: Guilford Press.
Sobell, M. B.. & Sobell, L. C. (1993). Treatment for problem drinker\: A public health priority. In
J. S. Baer, Cr. A. Marlatt. & R. J. McMahon (Eds.), Addic,tiuc, hrhctuior.\ ucro.\.s the /(jk.\ptrn: P~cwc~/I-
tion, treurmcnt, crnd policy issuc~.c (pp. 34-36). Beverly Hills. CA: Sage Publications.
Thorn. B. (1986). Sex differences in help-seeking for alcohol problems - I The barriers to help-seeking.
British Journcrl of Addiction. 81. 777-788.
Tuchfeld. B. S. (1976). Chtrnges in ptrttert1.c of alcohol IIJC \l.it/lorrt the crid c$fi)rrntr/ trccctment: An
e.rp/orrrtor:\ study of,former prohlrm drinker.5 (Final Report, Contract No. ADM 28 I-75-0023; RTI
Project 24U-I 158). Research Triangle Park. North Carolina: Research Triangle Institute.
Tuchfeld, B. S. (1981). Spontaneous remission in alcoholism: Empirical observations and theoretical
implications. Jorcrnul of Studies on A/~/to/. 42. 626-641.

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