From The Carlat Addiction Treatment Report, January 2018, Stigma and Addiction

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CATR: To start, can you please tell us a little more about your work at Harvard and Mass General?

Dr. Kelly: Sure. I’m a clinical psychologist by training, and for the past 20 years, I have spent a lot of time researching the addiction treatment and recovery processes. I’ve looked at the effectiveness of different treatments, their mechanisms, and how we can improve treatments. Clinically, I see addiction clients, and I work with individuals and families suffering from substance use disorders and related conditions.

CATR: That’s a lot of noteworthy experience, so I’m guessing you often deal with the issue of stigma and addiction, and how that affects our patients and their families. Can you tell us how you would define stigma and how it can affect people with addictions?

Dr. Kelly: Well, stigma is a condition that can be socially discrediting. When it comes to substance use disorders, internalized stigma can lead to feelings of shame. Often, people who suffer from addiction feel discriminated against. People also feel very bad about their behavior, and over time they get more disillusioned with themselves and their own ability to change. They become pervasively remorseful. I think one other thing to remember is that stigma and discrimination occur not only in active use, but also when people get into early remission and even sustained remission. We just completed this large national study, where we found that roughly 25%–30% of people in long-term recovery still experience discrimination and stigma. One way to view stigma is that it is a condition or behavior that makes discrimination socially acceptable (Wakeman SE and Rich JD, J Substance Use and Misuse 2018;53(2):330–333).

CATR: And from your studies, what might be another example of how that discrimination manifests?

Dr. Kelly: Well, there are micro discriminations and macro discriminations that can occur long after someone has already achieved full remission. Macro discrimination is more obvious. For example, being denied a promotion or a job after an employer learns of a person’s substance use disorder history would be a macro discrimination. The micro discrimination level is what I call personal slight: “People always assume I’m gonna relapse, and because of that, I’m always looked down upon.” People with substance use disorders realize that, even while in recovery or remission, the process of regaining trust can be a lengthy one.

CATR: We’ve also been reading about how the type of substance used can intensify the stigma felt by addiction treatment patients. Can you tell us more about that?

Dr. Kelly: Culturally, there may be a greater stigma toward those individuals who have used illicit substances as opposed to more licit ones, such as alcohol. For example, we know from studies that users of heroin or methamphetamine experience more shame and internalized stigma than those who need addiction treatment for a legal substance (Kelly JF and Westerhoff CM, Int J Drug Policy 2010;21(3):202–207). People are just more likely to have a harsher view of those with illicit substance use disorders.

CATR: It’s an interesting commentary on our society in general. Do you think there is more stigma attached to those who use illicit substances because those substances are tied to illegal behavior? Or are there other reasons?

Dr. Kelly: I certainly agree that stigma can be tied to illegal behavior, but I also think illicit substance use disorders are stigmatized because of the greater fear and alienation that society experiences when viewing substances that are not personally familiar. For example, most people have very little firsthand experience with heroin. Obviously, crime is a factor, especially when it comes to people who become desperate enough to, for example, steal money to buy drugs. These are the things that scare society in general, and when we’re scared, I think we tend to want to remove and ostracize the source of that fear.

CATR: What then becomes the impact on the patient?

Dr. Kelly: As a result, people with substance use disorders are ostracized. In addition, there is an increase in stigmatizing attitudes and beliefs. Individuals suffering from these disorders are less likely to acknowledge or accept their disorders, disclose their worries to others, or seek help. This only perpetuates the problem. To some degree, it becomes a question of misunderstanding. After all, it’s only really been recently understood that people who misuse substances have a clinical disorder. It’s still difficult these days for many people to think of addiction as a brain disease—particularly for people who have been victims of someone else’s behavior. There is also a duality here, where people will accept and agree that addiction is a disease of the brain, but still fear an addicted person’s behavior.

CATR: Do you feel that this is also connected to the notion of free will? In other words, society in general feels that most people who take illicit drugs freely make the choice to do so. How does this tie into stigma?

Dr. Kelly: Yes, this is definitely a factor. There is this notion of cause and controllability, which I think are two major contributing factors to stigma. With control, there is a societal feeling that people should be held accountable for choosing to take substances. Of course, as clinicians, we know that the brain—even to the point of poisoning itself to death—can go from being impulsive to compulsive. With someone who has a substance use disorder, there is obviously some kind of medical malfunction going on in the brain. We now understand the exact nature of this malfunction more than ever before (Kosten TR and George TP, Sci Pract Perspect 2002;1(1):13–20).

CATR: So, this is the conflict we face with stigma when it comes to society. But how about people who are misusing substances? Does their inability to control themselves or refrain from using substances factor into them feeling stigmatized when they can’t stop using?

Dr. Kelly: Yes, and this is where internalized stigma comes in. People often blame only themselves for their behavior. They don’t always buy into the notion that their brain is deleteriously affected and is compromising their ability to make rational decisions. So, people who are addicted will often say, “I did it myself. I’m to blame. I deserve it. I deserve punishment.” I think this confounds the issue. In reality, we know that with more frequent substance use, we see impairment in a person’s ability to make rational choices and follow through on them. This inability to follow through on a decision not to use is one of the criteria that define addiction (see DSM-5 criteria). It becomes a situation of increasing impairment in control and increasing ­powerlessness.

CATR: This seems like a good time to address treatment. Let’s start by talking about patient defense mechanisms, such as denial. For example, a person blows 0.25 on a breathalyzer test, yet claims, “I’ve had nothing to drink.” Or, the person rationalizes or projects, saying, “I drink because I have a stressful job.” Are these maladaptive attempts to prevent feeling shame and stigma?

Dr. Kelly: Yes. I think that’s most of what it is, a kind of impulse or motivation to engage in those kinds of psychological defense mechanisms. I think it’s led us as clinicians to develop more client/patient-centered approaches, such as motivational interviewing. The idea is to use a non-threatening approach to help the clinician relate better by seeing the world through the patient’s eyes. It’s the notion of empathy and an understanding of where the person might be coming from. I think a large part of that is a sense of people feeling insecure, ashamed, and guilty about their behavior and overconsumption of substances. So, I think a non-judgmental empathic approach can really help mitigate some of those defense mechanisms. It’s important for us as clinicians to understand that people are much more open and honest when they feel less threatened. For family members who want to help a loved one with a substance use disorder using a non-threatening approach, I recommend that they check out the Community Reinforcement of Family Training approach (or CRAFT; see http://bit.ly/2ACxVtH).

CATR: That’s excellent advice. But are there also things that clinicians should avoid saying or doing to avoid unintentionally stigmatizing their patients? For example, it’s probably good for a physician to use the phrase “substance use disorder” rather than “substance abuse.” Doesn’t the word “abuse” carry a potentially shameful or even illegal connotation, and thus the potential to stigmatize the patient?

Dr. Kelly: Yes. I agree, and I think that’s one major way that we can change our approach as clinicians. Terms like “abuse” are pernicious when we’re interacting with people who are coming in looking for help with a substance use disorder. We need to use proper medical terminology and help patients understand exactly what is happening inside of them. We need to let them know how their substance use disorder is tied to their central nervous system, and how that disorder is getting the better of them in terms of their ability to control it. I think if we can use the proper medical terms and explain the situation to patients simply and clearly, they will understand the nature of what’s happening.

CATR: I agree, but can this approach also be challenging for clinicians who want to be able to relate to patients or clients on their own terms and using patients’ own language?

Dr. Kelly: It can be a temptation to want to be liked by our patients by using what you might call “street terminology.” There’s a potential argument for trying to relate to patients in that way, but we must be very careful. As professional healthcare providers, we need to use language that will help communicate to patients that they have an actual medical disorder. We need to use words clearly indicating that a disorder has happened in the brain, and that each year this disorder is responsible for hundreds of thousands of premature deaths in America alone.

CATR: With that, are there any specific words or phrases we should use with patients?

Dr. Kelly: To keep things on a more understandable level and to avoid stigmatizing language, explain that there is a medical malfunction in the brain. Incorporate words that don’t tend to cause stigma. For example, when doing urine screens, use the terms “positive” or “negative,” rather than “clean” or “dirty.” We should use this language too among our colleagues in our clinical settings to help reduce stigma where we work. Also, talk about patients being in recovery and being in remission—use these terms just like you would with any other medical condition or psychiatric illness. If patients use negative terms that could lead to stigma, help them reframe using terms that are consistent with a treatable brain disorder.

CATR: Are there any final tips that you might have on how clinicians can manage stigma with patients?

Dr. Kelly: The other piece of advice I would give clinicians, whether they work in mental health, primary care, or any other setting, is that they get better informed themselves by obtaining some additional training and understanding about the nature of substance use disorders. I think most clinicians are eager to learn more about these conditions and how they manifest. Getting more educated on what causes stigma will empower a clinician to conduct better-informed conversations with patients regarding their substance use disorder. We have developed free information for clinicians at our Massachusetts General Hospital and Harvard-affiliated Recovery Research Institute (www.recoveryanswers.org) that also has an “Addiction-ary,” which contains language, terms and their definitions, and terms to use and to avoid in this context. Substance use and related conditions affect approximately 10% of the US population, and they influence many other social and medical problems that we try to treat, so expanding our knowledge as clinicians in this regard is important and likely to improve the quality of our care.

CATR: Thank you for your time, Dr. Kelly.