Impact of stigma on dual diagnosis patients

Case study

"Anna is a 24-year-old single Latina (male-to-female) trans woman who has struggled with symptoms of Post Traumatic Stress Disorder (PTSD) for the past 5 years, and was recently diagnosed with Opioid Disorder (ODD). She is currently being treated with buprenorphine for OPD and has been referred to you for psychiatric symptoms. Her trauma symptoms began after a sexual assault that occurred when she was a teenager.

Introduction

As a mental health professional, you are familiar with stigma and how it can affect treatment. Mental health patients often experience stigma in society at large, including in health care settings. In this case, you would not be surprised that Anna experiences stigma related to her PTSD and OPN. She has also been discriminated against because of her race and gender. Unfortunately, this is not unusual in many clinical settings. Anna's treatment and recovery program will need to directly address these complex issues of stigma and discrimination.

In this article, we will discuss how treatment can be built on respect for patients and the development of a healthy sense of self as central to the recovery process. This overarching issue will be the central problem that brings together all the elements of a comprehensive treatment program.

Neurobiological origins of stigma

Stigma can be found in any environment and can be directed at any subgroup. There is an automatic neurobiological brain response that causes people to distinguish themselves from unfamiliar "others. It is a protective biological function that increases the safety of the core group and generates fear of strangers. This response has been localized as preferential activation of the amygdala, an area of the brain that generates precognitive responses of aggression, fear and anxiety. A few hours of CME lectures are unlikely to reverse such deeply rooted biological functions. Many religious and philosophical traditions recommend a focus on compassion and exercises to put oneself in the place of the "other" as methods of correction. Models of "walking in the other's shoes" have long been identified as effective methods of change.

Overcoming the influence of stigma in the clinical setting

Unfortunately, it is relatively easy to create a stigma and direct it toward any subgroup that is "different" and easily identified. Reversing such an original brain function requires considerable effort. It may require intense exposure to new experiences and new information. How can mental health services design their training program to address this problem? Ronald W. Pies, M.D., recommended that we use our brains "to think and feel our way out of this way of thinking, and to behave with compassion and decency."

Recognizing and respecting our patients as individuals is at the core of standard psychiatric practice. Collecting a thorough longitudinal medical history as the first step in assessment is already standard practice. Listening techniques that are empathic, non-judgmental, and kind are crucial, as is recognizing our patients through attention to verbal and nonverbal cues. Writing a complete history with a dynamic formulation and presenting it to colleagues and supervisors should be a central part of any training program. None of this is new, but it requires that clinicians and trainees have time to both perform these examinations and provide intensive treatment when needed.

The treatment of any patient should begin with a thorough history and assessment of the condition. In this case, it is important to clarify her self-perception. How does she see herself? What are her goals? The patient and her physicians should have a general idea of her desired goals. Where does she want to go and how can we facilitate this process? Regardless of how dire her current situation is, the therapist should be able to recognize her potential for recovery and direct her efforts toward goals that will restore her self-esteem. Trabian Shorters described this process as asset formation. It is the beginning of the recovery process.

In these cases, most of the typical components of a psychiatric treatment plan can be used. Patients with substance use disorders (SUDs) and co-occurring psychiatric disorders will respond to the same psychopharmacological interventions and psychosocial treatments used in the general population. With the exception of benzodiazepines, most medications can be safely administered to such patients. Cognitive behavioral therapy (CBT), contingent situation management (CSS), and motivational interviewing (MI) are also used effectively for these patients. However, it is important to understand that successful treatment of other psychiatric disorders will not eliminate co-occurring disorders. To achieve effective recovery from both mental illness and co-occurring disorders, it is important that specific elements of disorder treatment be incorporated into the treatment of any mental illness. Fortunately, FDA-approved addiction medications (methadone, buprenorphine, naltrexone, disulfiram, acamprosate, varenicline, and nicotine replacement therapy) are successfully prescribed in these populations.

Finally, person-centered language is important for building relationships with patients. Even if patients use specific language to describe their experiences, researchers, clinicians, and others who interact with or communicate with cooccurring disorders should use neutral, person-centered language. This is language that reflects the disorder as only one aspect of the patient's life, not defining its essence. Using non-stigmatizing language in all of our conversations is a direct way to demonstrate care and compassion for people with SUD disorders and co-occurring mental illnesses.

Helping patients overcome stigma

Similarly, peer support programs such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA) and SMART Recovery can be an important element of recovery. It is important, however, to identify specific mutual-help programs that can accommodate patients with other mental disorders and those of a particular race or gender. Clinicians need to know which mutual aid programs in their area would be convenient for these patients. Unfortunately, there are some self-help groups and individuals in them who are biased toward patients with other mental illnesses or racial/gender identities. People in the mutual aid community are usually willing to determine which groups are acceptable and which are more problematic. Clinicians should refer patients to groups that will be favorable to them. Psychiatric patients should be especially careful to avoid groups that are negative about the use of psychiatric medications or SUDs.

Participation in groups in treatment facilities and in self-help programs is absolutely essential for the development of positive self-esteem and the construction of a new positive identity. Similar goals can be achieved in individual psychotherapy, but this path to successful recovery may be available at no cost to anyone who is able to identify a suitable self-help program. These aspects of group membership may be just as important, if not more so, than some of the more traditionally recognized elements of addiction recovery groups.

For these reasons, we strongly recommend referring patients to racially and/or gender appropriate self-help groups. In such an environment, long-term sobriety is most likely to be achieved. Studies have shown that participation in self-help programs is highly correlated with long-term recovery.