What Stigma?????

I can remember growing up in the sixties in an extremely affluent town in Connecticut. There were no alcoholics - only problem drinkers or those who could not hold their liquor. A sign of the times I guess, the country club attitude, or perhaps a combination of both. If you had a loved one with a mental health issue they were just “eccentric” Un-huh, that’s why every spring when they would go off their meds then run through the streets naked. Just eccentric.

No alcoholics, No mental health issues – therefore, no stigma.

God forbid, if you had a loved one that died of cirrhosis from alcoholism in those days. You begged the doctor to put anything down on the death certificate but that! Maybe call it a heart attack or some incurable disease.

As if your neighbors and friends did not know the truth. It was just not discussed. Well openly anyway.

Zoom ahead to now. Addiction is more openly discussed in families and social settings than ever before. Yet at times one can see that stigma is still prevalent and often ignored or downplayed. How else can one explain that up until a few years ago if a person was civilly committed in Massachusetts (Section 35) for mandated addiction treatment they would be sent to a correctional facility? That’s right a correctional facility, not a treatment facility.

I am glad to see that this ‘stigma’ piece has changed.

There are still those in our society that mumble, ‘you know those people want to be that way.’ I always find it interesting when these people change that attitude when it is a member of ‘their’ family is suddenly having an addiction issue. I guess it is just not the same thing.

Those people want to be that way? You know, I have yet to see it on a resume, ‘Professional Addict/Alcoholic.’ Yea I’m sure when they were growing up they were thinking, ‘you know, someday I want to become an addict/alcoholic; homeless, jobless, walking the streets, drinking a half-gallon of vodka a day.’ Yup, that’s what I want to do.

People who make those types of statements show their ignorance, they are part of the problem – not the solution.

There are other areas of mental health often times shrouded in stigma and secrecy. Why else would a family not talk about ‘Uncle Tony’ who has not worked in two years due to his depression, or, no one talks about the times when Grandma would make everyone a Sunday morning breakfast clothed only in an apron because she was in a full-blown episode of mania.

In the case of depression, one might hear encouraging words from family such as: ‘what do you have to be depressed about, just pick yourself up by the bootstraps, you know if you only had a job...

Gee, those motivating statements should do the trick. I do not understand how ‘putdowns’ of that type can be considered motivating. Yet I will hear family members say these statements during a meeting with their loved one.. Can someone explain to me how that works?

Yet these are statements that patients/clients tell me they can go through on a daily basis. There are support groups for the friends and families of those with addiction and/or other mental health issues.

Often times the patients/clients I work with tell me their families are not willing to attend such groups to learn about their illnesses due to the beliefs I stated previously.

The suggestion I make to them in that case is, look directly at them and say something to the effect, ‘you say you love me, and that you care about me, yet you won’t attend a group to learn about my illness…’ Some fellow therapists have told me this is unethical for me to suggest – so be it. I advocate for my patients/clients, bottom line.

We need to continue to have dialogue and education on addiction and mental health issues; we need to do away with ‘blanket’ statements that allow us to turn our heads away from those that are in need. We “all” need to be part of the ongoing solutions.

There is no place for ignorance and stigma if we truly care about our fellow human beings.

Therapist? Then You Need A Therapist…

Counter-transference, secondary trauma, boundary issues, etc. Issues such as these can build up and ‘burn out’ a clinician if not addressed over a period of time. When I am teaching a new group of addiction counseling students at UMASS-Boston this is one of the first topics I discuss with them.

The need to obtain a therapist for themselves.

Why, what is the big deal if I am already getting supervision? While supervision can be beneficial it will not necessarily address the underlying issues in depth. Time constraints, vulnerability, and the issue of not wanting to appear ‘unable’ to perform one’s duties can play into the limitations of supervision only.

I can recall instances over my years in field when I was extremely grateful to have my own therapist.

One time I was performing an intake with a 26 year old female recently to the U.S. from a Latin American country. When I got to the section of the intake asking about family and after asking her a question about her father her face became expressionless, her voice dropped an octave and she stared straight ahead and said ‘When I was seven years old men banged down the front door of our house and started beating my father up…I was hiding in a closet, the type that has slants in the door and I could see everything they were doing…they knocked him to the ground before they killed him…’ In the back of my mind I was screaming ‘are you f@#king kidding me!’ Toward the client I expressed appropriate empathy and spoke of wanting to line up clinicians that specialize in trauma issues.

For the rest of the day I was useless. I could not get her story out of my mind. When the day was over I was still thinking about it…walking to my truck, still thinking about, start my truck up, still thinking about. I turned my truck off, grabbed my cell phone and called my therapist. ‘Hey, do you have some time to see me this afternoon? I really need to talk about a situation that happened today. What, you have a full schedule? Well, I’m coming by anyway.’ (He found time for me).

Without dialogue with my therapist I probably would have taken this ‘situation’ home where directly or indirectly it would have affected my family – not to mention increasing distress to myself.

I always try to leave work at work.

Another time I had picked up a new client that had recently been released from prison after serving a term for vehicular manslaughter. I asked him how it felt to be out and he said he didn’t care if he had ever gotten out. He had been drunk driving and the passenger in his car had been killed in the accident. After more dialogue I learned that the passenger had been his twelve year old son he had been driving to a hockey game.


Another phone call to my therapist…




Willy is an educator at UMASS-Boston & Cambridge College where he teaches Substance Abuse & Co-Occurring Disorders as his principle course. He presents from a clinical, academic, and personal perspective. Recently he has started guest lecturing nationally at Universities, Colleges, and to Professional Organizations. His style is high energy, entertaining, and informative due in part to his previous life as a comedian and comedy writer.

Substance Abuse / Co-Occurring Disorders & 12 Step Programs

When I educate patients on community resources one of the first statements I make to them is that if you are attending, or, plan to attend traditional 12 Step meetings, please, please, for your own sake do not discuss or talk about any medications that you are prescribed and currently on for your Co-Occurring Disorder.

It just takes one person to hear what is being said and feel the 'need' to tell the person they are 'chewing' their booze, and that they are not sober.

Before going into more detail and examples, I feel I should state for the record that I am NOT ANTI-12 STEP. As a matter of fact, many people that are dual-diagnosed utilize traditional 12 Step meetings as their base of recovery. Traditional 12 Step meetings can help one to learn again (or for the first time) how to socialize without a drug or drink in their system. In addition, people attending these meetings share a common goal, namely, maintaining and fostering sobriety.

However, for those that are truly dual-diagnosed more often than not these meetings will not be enough in and of themselves for maintaining sobriety and balance.

Conflicts can arise for the dual-diagnosed person in these meetings with regards to some of the traditionally held sayings and beliefs.

Example: I had a client that was told at a meeting to, “Just go to another meeting.” Well, the fact of the matter was the client had been awake for five days and had attended eight meetings. What he really needed at that time was a medication adjustment for his bipolar disorder.

Example: “No one ever died from lack of sleep.” I have never sought research to confirm or deny this statement. I can tell you from working in the psych/addiction field for twenty plus years now is that people can become extremely paranoid, psychotic, and suicidal if they have been awake for three or four days in a row.

Example: “They broke out because they stopped going to meetings.” This is definitely a blanket statement. What if the person was ‘so depressed’ they could not get out of bed?

Example: “Bring the body the mind will follow.” Not if the mind is on Jupiter.

I recently had a patient I was working with inform me that his AA sponsor was telling him to get off the anti-depressant he is on. He asked me what he should do. I asked him if he felt the anti-depressant was working for him, he said yes. I told him I think you have your answer then.

So what are some of the other support groups? The first one I inform them about is DBSA - Depression Bipolar Support Alliance (www.dbsalliance.org/). In their own words: The Depression and Bipolar Support Alliance is a non-profit organization providing support groups for people with depression or bipolar disorder as well as their friends and family.

The largest group within these meetings is “Double Trouble.” This group is for people with substance abuse coupled to the aforementioned above. People who often times were trying to self-medicate. Many of these members also belong to traditional 12 Step groups as well.

In much the same way that 12 Step programs have sponsors, people in “Double Trouble” can find a sponsor that not only has their same addiction, but the other mental health issue as well; “you pace your kitchen at 3am agitated and drinking – I thought I was the only one!”

The reason support groups work for many people is the identification factor. I realize now that I am not the only person that has ever felt or feels the way I do. I am not alone.

Another group is DRA – Dual Recovery Anonymous (http://draonline.org/ ). This is a 12 Step based group. In these meetings people not only talk about their addiction issues, they also discuss other mental health issues as well. In traditional 12 Step if you want to discuss the other mental health issues you do so after the regular meeting (sometimes referred to as the meeting after the meeting).

DRA is relatively young compared to other support groups and meetings can be far and few between. Several months ago I had a couple of former patients drop by the program where I work and they were complaining about this very fact.

I had a suggestion for them. There are two of you, and it only takes two to have a meeting, right? So why don’t you contact DRA to get the materials needed to start a group of your own. They liked that idea (Hopefully they have done so).

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The New “Breed” of Addiction Counselors

The primary course I teach at the University of Massachusetts-Boston is ‘Addiction & Co-Occurring Disorders.’ This is in the Addiction Counselor Education Program which leads one to being eligible to become a certified and/or licensed addiction counselor. One of the first videos they see features Kim Mueser from Boston University (https://www.youtube.com/watch?v=cnUv-869AS8) discussing, ‘Sequential, Parallel, and Integrated Treatment.’

Many (if not most) of the addiction counseling students I encounter these days want to learn more about: CBT, DBT, EMDR, Affective Disorders, Personality Disorders, Trauma & Relapse, Smart Recovery, etc. They are more open to critical thinking and empirical studies (which either confirms or repudiates their views).

If they are in recovery themselves many understand now that what works for them may not work for someone else. Treatment should be based on the patient/client’s ‘story’ not on theirs. Do you really want to set-up an expectation based on what works for you? Then if they fail what do you say, ‘Ah, you didn’t work it the way I laid it out for you.’

When I began in the field some twenty-five years ago Twelve Step was the “Answer.” Considered by many to be the “only” answer. While Twelve Step can always be the base of a person’s recovery or at least part of the answer (if counselor and client decide together it is a good fit) it may not be enough in and of itself.

Try telling someone with a severe trauma history that well, you should get some clean time before you address those issues. Oh that should work out well. Let’s see, they are not self-medicating the flashbacks, they are in agony, and you think a meeting in and of itself will be enough? (check the NIDA studies on this topic)

Please note I am not attacking Twelve Step Programs. Many of us that are dual-diagnosed utilize Twelve Step as our base but we are also involved with other types of groups (guess I am out of the closet now, huh? lol).

Over the years the other disciplines would look at us as a ‘para-profession’ (many still do). You know, those addiction counselors think that Twelve Step is the answer to everything and conversely many in the addiction field looked at psych and felt all they wanted to do is get everyone on medications.

Maybe the attitude was also the result of the early days of addiction counseling; “Oh, you have six months sober, we’ll make you a counselor now.” While the times have changed with the establishment of addiction counseling education programs the attitude about us is still pervasive.

Addiction Counseling Education Programs such as the one I am involved in offer my course as an elective, not a requirement. Conversely, the other disciplines offer maybe one or two addiction courses (if that) and those are electives as well.

Something is wrong with this picture. I suggest to my students that if they really want to learn about addiction and mental health they should work for a year or two with the street people and/or inpatient psych/addiction. Get your clinical from the ground up.



Willy is available for Presentations on Substance Abuse & Co-Occurring Disorders. He presents from an academic, clinical, and personal perspective. For more information you can email him at: william.drinkwater@umb.edu.