Stigma and stereotypes inside the treatment arena.

It’s bad enough when substance misusing clients run into stigma, bias, prejudice and stereotyping as they try to navigate their life paths forward in recovery. It’s much worse when they receive poor treatment, or are refused treatment, within the medical and mental health arena itself, the very places that they look to for acceptance and care. Unfortunately, many clients are refused treatment because they present with addiction, while others receive poor treatment that can appear rote or even adversarial. Dr. Amy Colley discusses the conscious, or unconscious forces, that impact treatment professionals, forces that she herself is not immune to… Richard Juman.

“Treating substance misusers is challenging work, and many of the concerns that mental health professionals have regarding working with them are often valid.”

Those of us in the professional treatment community are all-too-familiar with the stigmatization that our substance misusing clients face with regards to employment, housing and many other aspects of society. What is less frequently commented upon is the conscious or unconscious bias towards substance misusers that our clients, and we as professionals in addiction treatment, encounter from within the medical and psychiatric establishment. A recent conversation I had with a therapist at a local student counseling center followed a pattern that I have become accustomed to over my 20 years of experience. She told me that she could not provide drug and alcohol treatment for “John,” the student I had referred to her.

I had sent him to the college counseling center because I knew it would be difficult for the 18-year-old to follow through with a referral to a traditional substance abuse treatment facility off-campus. Also, given the recent media coverage of alcohol abuse on college campuses, which has led to serious consequences and public outrage all over the U.S., I had naively figured that the college would be sure to have a good program in place to help students who were struggling with alcohol and drugs. I was worried about John, as he had already received a DWI, and had a parent who had died from the complications of severe alcoholism. He was at high risk for developing a severe problem with alcohol—if he did not already have one.

Over the course of our phone conversation, I began to have a sense of what was going on. After telling me “how much trouble this young man was in” regarding the incident that had brought him to my office for an evaluation, and how he had “no insight or motivation,” I realized that this counselor really just did not want to take on this case. She simply didn’t want to work with John because he was an alcoholic.

Sadly, such bias toward substance misusers is a common part of working in the field of addiction. Many psychiatrists and psychologists refuse to treat substance misusers, whose situations can seem too challenging, and often come with lots of complications including medical problems, personality disorders, family conflicts and legal issues. “Old school” thinking that addiction is somehow a moral failing rather than a complex biopsychosocial disorder is still prevalent. Psychiatrists worry about prescribing medication that will end up diverted or abused by the patient. Mental health professionals who refuse to work with substance abusers stereotypically see them as deceptive and prefer to work with individuals who do not present such challenges. Many social workers and therapists will only work with patients who are abstinent—claiming that substance use renders mental health treatment less effective or ineffective.

On the other hand, there are some psychiatrists who treat substance misusers with medically-assisted therapies such as naltrexone and Suboxone. Their practices do not always appear to be as “recovery-minded” or therapeutic as one would hope. One patient described to me his predictable monthly five-minute sessions: the psychiatrist would ask how he was feeling, write the script for Suboxone, and then take a cash payment.

I even battle with my own bias, both conscious and unconscious. After interviewing a young heroin misuser recently, I came away convinced that he was not truly interested in changing. He told me how he started selling drugs in high school, and about all the damage he had done to his family by getting arrested and stealing. I thought my chances of helping this guy were slim to none, because he was clearly not invested in helping himself. I felt myself shutdown and my suspicions rise up. I realized I had to take a step back and examine my countertransference and get a grip on my prejudicial thinking. Was it his nonchalance in telling his story that biased me against him? Was it his skinny, disheveled appearance? Was it my own feelings of hopelessness in the face of how to help this very troubled individual? After discussing this case with a colleague, I became clear about the path I needed to take. This young man was coming for help and despite his history and presentation, I had to put aside my bias and give him a chance. Read more “the fix”…