Battling Bias: Tales from an Addiction Psychologist

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Battling Bias: Tales from an Addiction Psychologist

By Amy J. Colley 04/16/15

Stigma and stereotypes inside the treatment arena.

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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.

As a private practitioner working with addiction, I often refer patients to psychiatrists to assist in addressing not only the addiction but also the underlying depression or anxiety, which can be driving the substance use. I once referred an attractive, elite athlete, who was also a successful saleswoman suffering with significant anxiety, to a local psychiatrist that accepted her insurance. When the patient came to me after seeing the psychiatrist, she burst into tears, describing how awful the woman had treated her. She said that she felt that because she had an alcohol problem, the psychiatrist treated her like a criminal; she refused to return to her for ongoing treatment. I felt frustrated that the psychiatrist, whom I had spoken to before she saw the patient, turned out to be so intolerant of this woman’s struggle with alcohol.

Since that incident, and many others where I have come up against biased mental health professionals, I have tried to refer patients to addiction-friendly practitioners. This, too, is a challenge—as few accept insurance and many of my patients do not have the financial means to pay out-of-pocket. I have had to hone my sales skills, persuading patients that working with a knowledgeable psychiatrist who really understands addiction is worth the few hundred dollars out of their pocket that they would normally would use to buy alcohol or drugs.  

One severe alcoholic, who came to sessions weekly, never followed through with the exercises I use to increase mindfulness about his drinking. He would come in and tell stories and discuss what was on his mind, but never brought in a drinking diary, identified his triggers or tried using any of the skills we discussed in sessions, despite my urgings. Each week, he would report heavy drinking of hard liquor to cope with the stresses he experienced on a daily basis between work and home. Each week, my anxiety would rise, convinced that this man was slowly killing himself, and that no matter what I provided therapeutically, there was nothing I could do to stop him. But at a certain point, about six months into treatment, the patient made a decision to stop drinking—utilizing some Valium he had at home to ease withdrawal symptoms. And he finally agreed to see an addiction psychiatrist that I had repeatedly urged him to see to get on naltrexone.

I am still unsure what ultimately led him to sobriety. Perhaps his recovery had to be on his own time and in his own way; perhaps it was having a safe, non-judgmental space to talk about whatever was on his mind that, over time, resolved his ambivalence about drinking. Whatever the agent of change may have been, I am convinced that therapy and medication saved his life. 

So what happened to “John,” the client that I was trying to refer for treatment to the college counseling center? After giving the counselor some space to vent her concerns, she revealed that she had worked in a drug and alcohol program for four years. My immediate thought was that she was experienced and knowledgeable about this population and therefore was quite capable of working with this young man. I felt that she would be able to understand his experience and give him a place to talk about why he uses alcohol. The counselor believed that he and his family had not fully processed the death of his mother.

Maybe this could be a therapeutic inroad to what was perhaps going on under the surface for this college student? Perhaps the four years spent working in a substance abuse program were difficult for this woman? Maybe she became burned out and vowed never to work with alcoholics again? Whatever the reason, my concern was to somehow get this woman not to give up on this student who had many strengths and a whole career and life ahead of him. We discussed what approach to take given his developmental phase and what I knew about effective treatment with college students. I offered my support, hoping that she could find a way to develop a good rapport and have empathy for a teenager who really needed help in moving away from a dangerous drinking pattern that might be taking hold.  

By the end of our conversation, she agreed to work with John despite her reservations. I encouraged her to call me for any support or help that she wanted or needed. I hung up the phone feeling like I had won the first battle after a lot of effort, but anticipated more to come in dealing with this case and counselor.

We all fall prey to stereotypes and prejudices. Treating substance misusers is challenging work, and many of the concerns that mental health professionals have regarding working with them are often valid. We clinicians are human beings with messy insides, and we need to be aware and vigilant of what happens internally as we treat this population. The insights and experience of other colleagues who work in addiction are extremely valuable in battling one’s own bias in treating addiction. With substance use on the rise, more and more mental health professionals will be faced with patients in their offices who initially present with depression or anxiety but then reveal a co-existing alcohol or drug problem. Hopefully, these professionals will be able to battle their biases, roll up their sleeves…and help.

Amy J. Colley, Ph.D. is a licensed clinical psychologist in private practice in Hastings-on-Hudson, New York. She recently returned from India where she lived with her family for eight months and studied alcoholism treatment in the state of Kerala. www.dramyjcolley.com

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