Destigmatizing addiction requires changing when professionals treat

As Michael Weiner noted in his recent article “Eliminate Stigma from the Inside Out,” we should keep doing the work of changing—our language, our attitudes, and our delivery of services. Here is my way of destigmatizing my professional role, my clinical work, and the challenges that the individuals and families I work for are experiencing. The model I use is a continuing work in progress.

I believe that all the individuals I have the privilege of serving are normal people. However, by the time they get to my office, many are in despair and are overwhelmed. They have lived with the symptoms and consequences of serious psychiatric disorders for so long that they believe they or their family member are their symptoms. These normal people with complex challenges want support, answers and realistic hope that these are treatable symptoms of psychiatric challenges.

I use Ken Minkoff’s Continuous Comprehensive Integrated System of Care (CCISC) model as an anchor point. I know that normal people with serious substance use and other psychiatric issues are not their symptoms, but have treatable and manageable symptoms of complex psychiatric challenges.

Interestingly, many individuals and families who come to the office tell me they heard about my services at recovery meetings. Others tell me they heard from another member of the community who is also having difficulty with symptom management (drinking alcohol at a bar, thinking about snorting cocaine at home, seeing and hearing things that others are not experiencing, ruminating about a family member’s symptoms and what they can do about them, etc.). They heard that I see people while they are symptomatic, which I do.

Many years ago, when I heard that I was being “marketed” or talked up in those settings, I took this as an affirmation that I was on the right path. We know that few behavioral health clinicians get a “good rap” at meetings or where people are symptomatic. So, I feel like I have been blessed.

I also see normal people who have decompensated (have used or are experiencing depression, delusions, intense rage, etc.) and are working on becoming stable again. I cheer them when they come in and are symptomatic, because they are, for the moment, safe and I can assess them and provide and/or link them to the services they ask for. They know I will be glad to see them, and that I will focus on their efforts to move forward in a meaningful way that makes sense for them, and to do the best they can today.

These normal people with challenges are of various cultural and socioeconomic backgrounds. When I first interact with them, I expect them to find their answers within their own socio-cultural perspective and context. I may offer additional options, but I will almost always defer to their perspective and ways of working things out. I will work on being culturally humble and curious to understand and explore their answers to these challenges. I consciously work to stay away from labels and professional jargon, as this can be experienced as shaming. Their own perspective and context may already include enough shame and stigma.

I know that normal people with serious substance use and other psychiatric issues will be engaged in services on an episodic and long-term basis as part of their treatment. This is to be expected. Starts and stops are normal as the need to change is incorporated into these individuals' and families' lives. Research shows that it reasonably takes three to five years for a normal person with complex psychiatric and physical health issues to become stable. I am in this for the long haul.

Individuals and families tell me that a periodic return to my office over several months or years occurs because I use a non-judgmental, unconditional positive regard approach when I see them. It is my professional responsibility to be able to make a clinical judgment, but not to judge.

I have seen time and again that individuals and families find support, answers to their questions about managing their symptoms, and realistic hope as they come to know that change is not linear but circular for anyone with chronic and persistent challenges. Out of this, they find that they can live a happier, more productive and meaningful life as they come to understand it on their own terms and in their own time.

For some, that means that they see me weekly for extended periods, while for others it will be episodic and long-term, and still for others they just utilize my services for linkage to another treatment setting.

A nod to the illness's complexity

Why do I use this framework and remain committed to it when discussing substance use and other serious psychiatric disorders?

Because just like other psychiatric challenges, substance use disorders are complex and perplexing conditions that affect individuals in varying ways. The affected individuals are afforded the right and expectation that they will find answers in their socio-cultural context and perspective. According to most codes of ethics, imposing cultural norms and values or any other set of beliefs as a prerequisite for initial and ongoing services is not appropriate. It is the individual's and family’s responsibility to find answers that work for them. My privilege simply is to walk alongside them as they strive to live a happier, more productive and meaningful life.

Because these individuals and families are like you, me and our families. Because these are normal people with a substance use or other serious psychiatric disorder, I do not call my clients by their illnesses. They can describe themselves as an “addict” or something else, but I consciously describe them as an individual experiencing treatable symptoms of a substance use disorder, trauma, or other serious disorder.

Because being symptomatic is expected for any chronic and persistent behavioral health condition. Symptoms will be more intense at different times and managed more or less effectively depending on various circumstances. These symptoms may be part of their world for the rest of their lives, and that is to be expected, accepted and affirmed as normal.

Because I was taught for all other serious psychiatric disorders that individuals with these challenges will decompensate at times. It is expected that they may need support to stabilize and move forward again, and it is part of the course of treatment. They do not relapse or slip. It is not a failure and they do not, as a matter of course, start all over again.

Because complex co-occurring disorders are the expectation today. I need to be trained and prepared to address a variety of issues when providing services. Asking a community member to go somewhere else to get help with that other disorder is no longer acceptable.

Because asking individuals and families to be asymptomatic before I will serve them is not acceptable, as I do not ask that for other psychiatric disorders. Also, addressing other psychiatric symptoms as triggers needs to be openly discussed, supported and integrated into a co-occurring disorder recovery care plan.

Because I have come to believe that I was taught wrong about the treatment and management of substance use disorders and the symptoms associated with them, and, most importantly, the normal people with these challenges. I must continue to evolve and learn newer and better ways to view, interact with and serve these individuals. Symptom management is the goal, up to and including abstinence if that is what the individual/family desires, while pursuing a happier, more productive and meaningful life on their own terms.

Because service coordination and integration requires me to change as much as or more than the individuals and families that I serve. I have the privilege of serving them, and doing this to the best of my ability is therefore mandatory.

And finally, because I accept and believe that substance use disorders are a class of psychiatric disorders. As such, I can treat them using evidence-based practice models similar in many ways to those for other psychiatric disorders. I advocate for and can develop a broader continuum of care that is accepting, destigmatizing and non-judgmental of individuals/families with substance use disorders, whether they are symptomatic or not.

Let’s continue to lessen the shame and destigmatize those we serve, their challenges and symptoms, and the valuable work we have the privilege of doing with these individuals and families.

Les C. Lucas, LMFT, has worked in the behavioral health field since the early 1970s. He is a family therapist who supervises a rural crisis triage team under a county contract in central California. Lucas also has a part-time private practice in Fresno, Calif. He can be reached at leslucas@kingsview.org.