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Special Topic: Examining Addiction Stigma and Countertransference

Professionals working in the field of mental health and substance abuse treatment are expected to be completely impartial, accepting, and unbiased in our approach to treating those we serve and yet many struggle under the weight of their own humanity. Can anyone really say that each and every day, with each and every Individual served, we as clinicians are able to effortlessly put aside our thoughts, feelings, and perceptions pertaining to issues such as addiction, entitlement, and dysfunction and meet each person “where they live” or “walk a mile in their shoes?” It seems that almost every day we are inundated with stories and media reports of people from all walks of life whose lives and the lives of those closest to them are destroyed by drug addiction, a barrage of hopelessness and despair emanating from an ever-widening culture of desperation. Stories of the darkest forms of cruelty and abuse against families, innocent children or unsuspecting victims of crime, and violence loom large in our consciousness as our Society’s dependence on drugs continues to spiral out of control. So how do we as human beings, first, and Mental Health and Substance Abuse professionals, second, find balance and come to a place of acceptance and effectiveness necessary to carry out our mission to provide the best care available to those we serve? How do we keep our own judgments, fears, and opinions from tainting delivery of services to those who are literally dying to receive them? How do we find motivation when faced with such a daunting task? Much of the answer lies within each of us and I feel it is important to examine two key factors contributing to our own limitations-stigma and counter transference.


Stigma is defined as “a mark of disgrace or infamy; a stain or reproach, as on ones reputation.” A recent article on stigma by David L. Rosenbloom states: “Stigma is one of the meanest and most difficult aspects of addiction because it makes it harder for individuals and families to deal with their problems and get the help they need. Society imposes stigma-and its damage-on addicts and families because many of us still believe that addiction is a character flaw or weakness that probably can’t be cured.” This belief system is widespread throughout our society and is shared by some in the Mental Health profession, despite recent advances in treatment. It seems that perceptions toward the addicted mirror those who used to believe mental illness was a character deficiency and yet through education and societal evolution those with mental illness are finding increased tolerance and respect while much is left undone to change perceptions concerning the addicted. Accepted speech relating to drug addicts and alcoholics often times includes terms such as “crack head, crankster, spun out, drunk and dope fiend” among others all of which encourage visions of dirty, emaciated, and immoral individuals seeking to get high no matter what the cost to themselves, family, or society. And many times throughout our careers or personal lives we have witnessed first hand intense suffering either by the addicted or those closest to them such as their children. Addiction or substance abuse is present in the majority of molestation, domestic violence, murder, and sexual assaults and it is certainly easy to see how as a society we begin to form attitudes colored by an innate sense of hopeless, fear and anger. Drug addicts have been elevated to almost mythical status, portrayed in movies and television as dangerous, selfish, cruel, weak-willed, and unrepentant, looked upon by society as being destined to fill our prisons, mental health clinics, and cemeteries. This stigma is the reason why there is so much societal and legal discrimination existing toward addicts and their families. It is why the addicted are thrown into a single category and looked upon with scorn by so many. It is the reason why many truths about the addicted are overlooked and why so many Mental Health Professionals feel ineffective and fearful when treating addicts. And it most certainly is the reason the very thing that can save the lives of many millions of people, treatment, is often times not accessed or is out of reach. In order to overcome stigma in our profession certain facts must be acknowledged.


Fact #1- Addicts are people and individuals and must be treated as such. The majority of addicted citizens in our country are able to hold jobs, pay taxes, and have families they are supporting and who love them. Only a small percentage of addicts resemble “skid row” bums or live in filthy squalor. Mental Health agencies that provide low-cost services or rely on Government funded insurance like Medi-Cal for the majority of their funding will typically see only one segment of the total addiction population. Across the nation there are many programs whose populations are made up of middle to upper-class patients that will resume their lifestyle once treatment is completed.


Fact #2-Addiction is not about willpower, weakness, or moral deficiency. People who have never been educated to the true nature of addiction struggle to understand what addicts truly go through and are less likely to focus upon the origins of the disease in those they encounter. No one ever stood up in kindergarten when the teacher asked, “What do you want to be when you grow up?” and said, “I think I’ll become meth addict.” The majority of addicts try drugs or alcohol at a young age before they are educated on the facts about the consequence or predisposition to addiction. Addiction lodges itself in and emanates from the brain stem, which is home to the limbic system, containing the automatic area of the brain. The limbic system stimulates our sense of smell, sex drive, and complex emotional responses. Actions that occur without thought making the process of having addiction “hard-wired” extremely easy. Addicts soon find they can no more control urges to use than the non-addicted can control sexual attraction or feeling sad when overcome by grief. Educating ourselves on risk factors and brain chemistry associated with addiction are powerful weapons to combat this disease and put us more at ease when treating cooccurring clients and can assist us in helping addicted clients move through the stages of change.


Fact #3- Change must begin within ourselves. To overcome stigma we must look inward and be courageous enough challenge the prejudices we hold toward our Nation’s addicted citizenry. Victims of stigma internalize the hatred it carries turning it into shame and hiding from its impact, they live in the shadows of many scared and uninformed person’s projections of moral superiority or fear, afraid to come into the light. They begin to believe that addiction is their own fault accepting societies notions that they are weak and have low character, feeling unworthy and alone. This is particularly true of adolescents whose struggles to find an identity leaves them susceptible to gangs and drug-using peers. Many use to fit in or cope with pressures. Use turns to abuse and finally addiction and when discovered by the adolescents the stigma of being exposed as an addict leaves them by themselves struggling with a problem that neither themselves or those closest to them understands. Then, when parents discover their child’s addiction, stigma leaves them feeling negligent and guilt-ridden. Fast-forward to an office visit with a therapist or counselor whose views of addiction and treatment competency have been shaped by stigma and the addicted individual’s view of themselves and the problem becomes their reality- “I am who you say I am.” Like it or not addiction is a disease and we must embrace this concept just as we embrace the fact that cancer, diabetes, and mental illness are all diseases worthy of effective, empathetic client-driven treatment. As professionals we must know the person first, their hopes, dreams, and aspirations, and we must make every door an open door with every individual we serve being met with hearts driven by compassion and minds armed with knowledge.


Fact #4- Addicts do recover and we can all be a part of the solution. The process of recovery from addiction as with a great many others diseases may be agonizingly slow but when stigma is pulled from the equation we are able to “go the distance” much as we would with schizophrenia, persons with borderline personality disorder, or others suffering from various mental illnesses. Cooccurring clients respond well to Cognitive Behavioral therapies many of you are already practicing and if one is uncertain how to apply these disciplines it is recommended to consult those practicing substance abuse treatment, I think you will find it a lot easier than you thought. Overcoming fears and stigma associated with treating addicted or co-occurring clients becomes less anxiety provoking when those on the mental health side and those on the substance abuse side come together and share the vast knowledge of their experiences and education. A professional’s ability to apply to him or herself the very same skills he or she imparts upon those served is critical to overcoming anxiety, doubt or fear, and foster willingness “to put yourself out there.”


Fact #5- Countertransference contributes to stigma. Countertransference occurs when past experiences create judgments or prejudices toward a particular client or group of people. Clinicians need to be aware of strong personal biases toward clients, obtain further supervision where countertranseference is suspected and is interfering with continuity of care, and an atmosphere must be created in which clinicians may openly discuss difficulties with countertransference. Seeking guidance and support from others alleviates feelings of incompetence and going at it alone.


While it is uncertain whether we can change the world we can most certainly change our hearts and minds and in doing so we can bring about change IN the world. The eradication of stigma must always be in the forefront of treatment and our mission relies on our ability to challenge ourselves in new and exciting ways and also in times of quiet reflection. Will you answer the call?


By John French SASII

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