Hope not heart-sink: is stigma the main barrier to help and recovery for people with Dual Diagnosis

Elizabeth Hughes (School of Health and Human Sciences, University Of Huddersfield, Huddersfield, United Kingdom)

Advances in Dual Diagnosis

ISSN: 1757-0972

Article publication date: 17 August 2015



Hughes, E. (2015), "Hope not heart-sink: is stigma the main barrier to help and recovery for people with Dual Diagnosis", Advances in Dual Diagnosis, Vol. 8 No. 3. https://doi.org/10.1108/ADD-07-2015-0014



Emerald Group Publishing Limited

"Hope not heart-sink" is stigma the main barrier to help and recovery for people with Dual Diagnosis

Article Type: Editorial From: Advances in Dual Diagnosis, Volume 8, Issue 3

People with co-occurring mental health and substance use continue to experience significant inequalities and I am not convinced that significant progress is being made in terms of addressing this. We still commission and deliver services in a model that is driven by a primary diagnosis with limited integration. Substance use is a particular issue in that it is not a key feature of nurse education, for example, and therefore in general medical settings as well as mental health settings a variety of attitudes, misconceptions and discrimination can occur.

As discussed many times in this Journal, individually delivered and manualised interventions are not going to be sufficient to engender more positive outcomes and recovery for people with co-occurring mental health and substance use. People whose problems are multi-faceted in both their development and maintaining factors require a comprehensive and long-term approach. One of the keys to this is to retain people in a treatment system that not only provides the elements of treatment required (what people want and need) but also operates in a culture of openness and acceptance. In any consultation with people with lived experience of co-occurring mental health and substance use, the consistent theme is one of exclusion, a lack of empathy and understanding, and rejection by the very services that should be opening the door. As we know, people with multiple needs have experienced a great deal of adversity in their lives, and I can't help feeling that the healthcare response is one that compounds peoples' sense of hopelessness and low self-esteem. After all, if the services can't see and communicate a positive future for you, how can you get motivated yourself?

One of the most significant barriers for people with co-occurring mental health and substance use is likely to be stigma. Stigma is a mark or sign of "difference" often leading to being shunned and excluded. In terms of conceptualisation stigma is seen as consisting of issues of lack of knowledge or misinformation, negative or pejorative attitudes (prejudice) and the consequent behavioural responses (such as discrimination, exclusion, inequity) (Thornicroft et al., 2007). The media contribute in negative ways to feed stigma with reports portraying people with mental illness as dangerous and less human. Stigma associated with mental illness has been long established and in fact a great deal of effort has been put into challenging this at a national level in the UK (Time To Change) and Australia (Say No to Stigma). In the UK, Time to Change anti-stigma campaign has demonstrated some success with reducing stigma towards mental illness in the general population (Henderson and Thornicroft, 2013) but has reported less impact on mental health staff (Corker et al., 2013). Stigma as experienced by people with co-occurring mental health and substance use is less well understood (Evans-Lacko and Thornicroft, 2010). However, it is likely that this group will experience significant discrimination.

There is an urgent need to understand stigma as experienced by this group, and also to investigate staff attitudes and behaviour in terms of inclusion into services, and attitudes of hope and optimism. This serves as a major source of health inequality and one that we should all be very concerned about. So I am pleased to say that this issue contains three papers from the UK, Australia and Norway that all address stigma and barriers to healthcare for people with dual diagnosis from a variety of settings and methodology.

Gronkjaer and colleagues from Melbourne, Australia, report on a qualitative study of mental health and Alcohol and drug service practitioners regarding the barriers to care for people with co-occurring substance use. They found that stigma and subsequent reluctance of services to engage with this client group was a significant concern. Practitioners were trying hard to do the best they could but were constrained by lack of training and support, as well as constraints of the services in terms of accessing services when an opportunity for change arose (such as a person wanting to stop drinking only to be faced with several weeks wait for detox). They also noted that all these issues especially stigma was exacerbated in people of aboriginal and "culturally and linguistically diverse" (CALD) groups and refugees. The findings highlight the need for coordinated and integrated, individualised holistic comorbidity services, including treatment and care best suited to aboriginal people and CALD groups.

Gore and colleagues report on a qualitative study which aimed to understand the experience of participating in a feasibility RCT of psychological therapy for substance users who had co-morbid depression. In the interviews, barriers to accessing psychological therapies were identified. These include cognitive impairments leading to forgetting appointments, the challenge of managing multiple appointments over different sites (when trying to manage a substance use and depressive illness) as well as reluctance to attend a different service other than the familiar substance use service. The importance of co-locating psychological therapies within substance use services is suggested as a possible way of facilitating engagement and maximise the benefit of psychological therapy.

Saelor and colleagues report on an action research project which focused on understanding how staff can engender hope in their work with people who have both mental health and substance use. Practitioners saw the importance of maintaining their own sense of hope as a way of engendering hope in the people they worked with. They also saw the importance of seeking supervision to help them keep positive, as well as the importance of the use of language and body language in being person centred.

Hamilton and colleagues have undertaken an analysis of large data sets (Hospital Episode Statistics and British Crime Survey) to examine gender differences in cannabis use and psychosis. They found that male cannabis users outnumber female users by 2:1 and a similar gender ratio is found for those admitted to hospital with a diagnosis of schizophrenia or psychosis. However, the gender difference is even more pronounced for admissions specifically for cannabis psychosis (with males outnumbering females by 4:1). The explanation for this increase in the gender divide specifically for cannabis psychosis warrants further investigation and also highlights the importance of considering gender in research and treatment provision.

In sum, it seems that if we want to improve how we offer help and support to people with co-occurring mental health and substance use, we need a radical change to how services are commissioned and delivered, as well as a shift in the values and attitudes of those people who provide front line care. We need more integration of mental health and substance use (including co-location) as well as providing support, training and supervision for staff to help keep their sense of optimism and hope alive. Most importantly we need to listen carefully to what people with lived experience say. I have "borrowed" the quote for the title of this editorial from a consultation meeting I had with Zip Group in Leeds, UK (a service user led expert reference group for dual diagnosis in the city of Leeds). They talked openly about the challenges they faced in getting help. They said they want to be accepted and welcomed, treated with dignity and respect, and valued as human beings. They also talked about optimism and that they wanted "hope, not heart-sink". Sounds so simple, doesn't it? Surely we can do this ….

We hope that we can return to these topics in future issues.

Elizabeth Hughes


Corker, E., Hamilton, S., Henderson, C., Weeks, C., Pinfold, V., Rose, D., Williams, P., Flach, C., Gill, V., Lewis-Holmes, E. and Thornicroft, G. (2013), "Experiences of discrimination among people using mental health services in England 2008-2011", The British Journal of Psychiatry, Vol. 202 No. s55, pp. s55-s63

Evans-Lacko, S. and Thornicroft, G. (2010), "Stigma among people with dual diagnosis and implications for health services", Advances in Dual Diagnosis, Vol. 3 No. 1, pp. 4-7, available at: http://dx.doi.org/10.5042/add.2010.0187

Henderson, C. and Thornicroft, G. (2013), "Evaluation of the Time To Change programme in England 2008-2011", The British Journal of Psychiatry, Vol. 202 No. 9679, pp. s45-s48.

Thornicroft, G., Rose, D., Kassam, A. and Sartorius, N. (2007), "Stigma: ignorance, prejudice or discrimination?", The British Journal of Psychiatry, Vol. 190 No. 3, pp. 192-193

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