Impact of Stigma for Patients With Dual Diagnosis
What is the clinician’s role in reversing stigma for better outcomes?
motortion_AdobeStock
Case Study
“Anna” is a 24-year-old Latina single transwoman (male to female) who has struggled with symptoms related to posttraumatic stress disorder (PTSD) for the past 5 years and was recently diagnosed with opioid use disorder (OUD). She is currently being treated with buprenorphine for her OUD and has been referred to you for treatment of her psychiatric symptoms. Her trauma symptoms began following a sexual assault that occurred when she was in her teens.
Introduction
As a mental health professional, you are acquainted with stigma and how it can impact treatment. Psychiatric patients often experience stigma in the general community, including in health care settings. In this case, you would not be surprised that Anna has experienced stigma related to her PTSD and OUD. She has also been discriminated against because of her race and gender. Unfortunately, this is not an unusual presentation in many clinical settings. Anna’s treatment and recovery program will need to deal directly with these complex issues of stigma and discrimination.
This article will spell out how treatment can be structured around respect for patients and the building of a healthy sense of self-esteem as a central element in the recovery process. This overarching issue will be the central issue that pulls together all the elements of a complex treatment program.
The Neurobiological Origins of Stigma
Stigma can be found in any environment and can be directed toward any subgroup. There is an automatic neurobiological brain reaction that leads individuals to distinguish themselves from unfamiliar “others.” This is a protective biologic function that enhances the safety of the core group and generates fear of strangers. This reaction has been localized as a preferential activation of the amygdala—the brain region that generates precognitive reactions of aggression, fear, and anxiety.1 A few hours of CME lectures are unlikely to reverse such deep-seated biologic functions. Many religious and philosophical traditions have recommended a focus on compassion and exercises for placing yourself in the position of the “other,” as remedial techniques. Models for “walking in the shoes of the other” have long been identified as effective techniques for change.2
Overcoming the Effects of Stigma in the Clinical Setting
Unfortunately, it is relatively easy to generate stigma and to direct it toward any subgroup that is “different” and easily identified. Reversing such a primal brain function requires significant effort. This may require intensive exposure to new experiences and new information. How can a mental health service design its training program to address this problem? Ronald W. Pies, MD, has recommended that we use our brains “to think and feel our way out of that mindset, and to behave with compassion and decency.”3
Getting to know and respect our patients as individuals is at the core of standard psychiatric practice. It is already standard practice to collect a careful longitudinal patient history as the first step in an assessment. Listening techniques that are empathetic, nonjudgmental, and kind are critical, as is getting to know our patients through attention to verbal and nonverbal cues. Writing up a comprehensive history with a dynamic formulation and presenting it to your peers and supervisors should be a central part of any training program. None of this is new, but it requires that clinicians and trainees have the time to both perform these evaluations and provide intensive treatment if needed.
With any patient, treatment must begin with a thorough history and assessment. In this case, it is important to clarify her self-image. How does she see herself? What are her goals? The patient and her clinicians must share a common sense of aspirational goals. Where does she wish to go, and how can we facilitate that process? No matter how grave her current situation, her therapist must be able to recognize her potential for recovery and focus her efforts on goals that will restore her self-esteem. Trabian Shorters has described this process as asset framing.4 This is the beginning of the recovery process.
Most of the typical components of a psychiatric treatment plan can be utilized in these cases. Patients with substance use disorders (SUDs) and cooccurring psychiatric disorders will respond to the same psychopharmacology interventions and psychosocial treatments that are utilized in the general population. With the exception of benzodiazepines, most medications can be safely prescribed to such patients.5-8 Cognitive behavioral therapy (CBT), contingency management (CM), and motivational interviewing (MI) have also been used effectively in these patients.9 It is important to recognize however that the successful treatment of other psychiatric disorders will not resolve cooccurring SUDs. To achieve effective recovery for both the mental illness and cooccurring SUDs, it is important that specific elements of SUD treatment be integrated into the treatment program for any mental health condition. Fortunately, US Food and Drug Administration (FDA)-approved medications for addiction treatment (methadone, buprenorphine, naltrexone, disulfiram, acamprosate, varenicline, and nicotine replacement therapies) have all been prescribed successfully in this these populations.8
Lastly, person-centered language is important in building the relationship with the patient. Even when patients use particular language to describe their experience, researchers, clinicians, and others who interact with or communicate about cooccurring disorders should use neutral person-centered language. This is language that reflects the disorder as only 1 aspect of the patient’s life that does not define who they are. Using nonstigmatizing language in all our conversations is an immediate way to demonstrate care and compassion to those with SUDs and cooccurring psychiatric conditions.10
Helping Patients Progress Beyond Stigma
Similarly, mutual-support programs such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and SMART Recovery can be an essential element of recovery.11 It is important, however, to identify specific mutual-support programs that are comfortable welcoming patients with other health mental disorders and individuals in specific racial or gender groups. Clinicians should be aware of which mutual support programs in their area will be comfortable for these patients. Unfortunately, there are some mutual support groups, and individuals within mutual support groups, who are biased against patients with other psychiatric diseases or racial/gender identities. Individuals in the mutual-support community are usually willing to identify which groups are accepting and which groups are more problematic.12 Clinicians should guide patients toward groups that will be affirming for them. Psychiatric patients need to be particularly cautioned to avoid groups that have negative attitudes about the use of medication for psychiatric disorders or SUDs.9
Group membership in the treatment setting and in mutual-support programs is absolutely critical for developing positive self-esteem and for building a new positive identity. Similar goals may be reached in individual psychotherapy, but this path to successful recovery may be available free of charge to anyone who is able to identify the appropriate mutual-support program. These aspects of group membership may be as important as, if not more important than, some of the more traditionally recognized elements of addiction recovery groups.
For these reasons, we strongly recommend that patients be referred to mutual-support groups that match their racial and/or gender identities. Such an environment has the best chance for achieving enduring sobriety. Research has shown that participation in mutual-support programs is highly correlated with long-term recovery.11
The Clinician’s Role in Reversing Stigma
This leads us back to the question of how stigma can undermine recovery programs for patients with both psychiatric disorders and SUDs. Recovery is driven by hope—both the clinician and the patient must share the view that recovery is possible. Recovery coaches are particularly effective in this role. All involved clinicians must support the patient’s aspirational potential for achievement and success in life. Whenever possible, the clinician should avoid any undue focus on the patient’s failings or negative self-image. Encourage the patient to explore their dreams and aspirations; avoid dwelling on past failures. How can their skills be translated into legitimate and rewarding activities? Always try to reward successes and, when possible, ignore failures.4
The clinician’s attitude and language are particularly important. The patient must be treated with respect at all times. Stigmatizing or discriminatory language must be avoided whether it is related to race, gender, psychiatric diagnosis, or substance use.10 Whenever possible, treatment program policy and procedures must avoid degrading or penalizing patients. Limit setting must be realistic and appropriate, yet guided by these affirming principles. If urine toxicology testing is required, the results must be used to guide treatment and identify needed services—never to penalize patients. Discharge from treatment should be the absolute last alternative.
The options for recovery and continued access to needed services are always the most important criteria. Even if a patient’s behavior makes it impossible to retain them in their current treatment situation, every effort should be made to transfer them to an alternative program that can better accommodate their needs.
The BUMC Psychiatry Program
In the Boston University Medical Center (BUMC) general psychiatry program, we have developed an experience in addiction psychiatry that is designed to provide these opportunities. It has been recognized as a model for reversing stigma and encouraging psychiatry residents to seek out opportunities to treat patients with SUDs and cooccurring mental health problems. All third-year psychiatry residents are assigned to the VA dual-diagnosis outpatient clinic for 20 hours a week for the full year. This continuity clinic is followed by a fourth-year 4 hours per week, with continued rotation in the same setting; the residents are therefore able to follow this group of patients for a potential 2 years of treatment. Typically, treatment begins after an inpatient admission for medical withdrawal treatment; the residents then treat both the SUD and any other cooccurring psychiatric problems for the next 2 years.
As the patients progress in their recovery, the frequency of visits is typically tapered from 2 or 3 a month to once a month in the fourth year. Residents have the opportunity to follow patients through any early relapses and into stable recovery. During the third year, there is a robust didactic curriculum for 2 hours each week. This includes case presentations, patient interviews, a wide range of seminars in SUDs and addiction pharmacotherapy, and introductions to the basics of CBT and MI.13
At the end of this experience, the residents not only have become comfortable treating patients with the full range of common outpatient psychiatric disorders—they have also become comfortable working with patients with all the common SUDs including OUD, alcohol use disorder, stimulant use disorder, and cannabis and tobacco use disorders. As they get to know their patients well, the discomfort and stigma that often characterized their first patient contacts has been replaced with caring and often enthusiasm for working with this population. They learn the high level of clinical effectiveness of methadone and buprenorphine and come to appreciate the clinical enthusiasm that characterizes addiction clinicians.2
Concluding Thoughts
Anna, and many patients like her, can engage and be successful in treatment with psychiatrists and other mental health professionals who demonstrate compassion and recognize their own biases. Stigma impacts the way individuals with cooccurring SUDs and psychiatric disorders engage in the mental health system. As demonstrated by the BUSM general psychiatry residency program, any outpatient psychiatry clinic can be adapted to both successfully treat dual-diagnosis patients and help address the stigma that often characterizes the treatment experiences of these patients.
Dr Renner is a professor of psychiatry at Boston University. Dr Durham is clinical associate professor of psychiatry and pediatrics at Boston University School of Medicine.
References
1. Sapolsky RM. Behave: The Biology of Humans at Our Best and Worst. Penguin Press; 2017.
2. Renner JA. Counteracting the effect of stigma on education for substance use disorders. Focus (Am Psychiatr Publ). 2019;17(2):134-140.
3. Pies RW. Are we “hardwired” for hatred? Psychiatric Times. December 6, 2018. Accessed March 10, 2022. https://www.psychiatrictimes.com/view/are-we-hardwired-hatred
4. The power of perception. TrabianShorters.com. September 30, 2021. Accessed February 27, 2022. www.trabianshorters.com/the-power-of-perception
5. Nunes EV, Levin FR. Treatment of depression in patients with alcohol or other drug dependence: a meta-analysis. JAMA. 2004;291(15):1887-1896.
6. McHugh RK. Treatment of co-occurring anxiety disorders and substance use disorders. Harv Rev Psychiatry. 2015;23(2):99-111.
7. Carey TL. Use of antidepressants in patients with co-occurring depression and substance use disorders. Handb Exp Pharmacol. 2019;250:359-370.
8. Aoun E, McCance-Katz EF. Psychiatric comorbidity. In Renner JA, Levounis P, LaRose AT, eds. Office-Based Buprenorphine Treatment of Opioid Use Disorder. 2nd ed. American Psychiatric Association Publishing; 2018:209-235.
9. Friedman PD, Park TW. Psychosocial and supportive treatment. In Renner JA, Levounis P, LaRose AT, eds. Office-Based Buprenorphine Treatment of Opioid Use Disorder. 2nd ed. American Psychiatric Association Publishing; 2018:145-162.
10. Volkow ND, Gordon JA, Koob GF. Choosing appropriate language to reduce the stigma around mental illness and substance use disorders. Neuropsychopharmacology. 2021;46(13):2230-2232.
11. Kelly JF, Hoeppner B, Stout RL, Pagano M. Determining the relative importance of the mechanisms of behavior change within Alcoholics Anonymous: a multiple mediator analysis. Addiction. 2012;107(2):289-299.
12. The A.A. member—medications & other drugs. Alcoholics Anonymous. 2018. Accessed March 10, 2022. https://www.aa.org/aa-member-medications-and-other-drugs
13. Renner JA Jr. How to train residents to identify and treat dual diagnosis patients. Biol Psychiatry. 2004;56(10):810-816.
