Developing Inclusion webinar - your questions answered.
‘Developing Inclusion - Substance Use Related Stigma Across General Practice’ is the latest in our webinar series, and as we’ve done previously we have posed all of the questions asked to our guest speakers and captured their thoughts and observations here.
We’re really grateful for all of the time and expertise that Dr Hugh Gallagher, Dr Bern Hard and Dr Joss Bray brought with them on the day, thanks also to everyone who joined, listened in and asked questions. We aim to keep the lines of communication and our conversations around stigma open and inclusive. We are listening. If you have an idea you would like to put forward please get in touch, we would love to hear from you.
If you didn’t get a chance the webinar live, we’ve just posted it on our new YouTube channel: https://youtu.be/zEPZBvYifcA?si=dmDAC17_mqjJyiTX
Questions & Answers
Comment: Not a question, but a general observation. I agree that competent compassion (CC) should (be) one of the gold standards of any service, let alone SUDs services. However, I do believe that CC has to go hand in hand with transformation of services with a strong emphasis on developing staff EQs at all levels of service deliveries including at policy, commissioning, developing QA system. Not everyone has compassion skills. However, we all have an inner voice to relate to when we are caring for others.
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Dr Hugh Gallaher: Totally agree
Dr Bern Hard: Compassion is not a skill. It’s a feeling.
a strong feeling of sympathy and sadness for the suffering or bad luck of others and a wish to help them (Cambridge English Dictionary)
You cannot mandate compassion, or kindness. You can mandate for a set of professional behaviours for sure, but you can’t tell people that they must feel a certain way.
It is even more of a challenge when ones competence allows us to evaluate what care our patient requires, and our natural compassions results in a genuine sadness, and a strong desire to provide this care, which is then blocked by failing services. This leads to moral injury and burnout.
This is not isolated to addiction services. It is everywhere we look. GP’s having to tell patients there is over a year’s waiting list for an orthopaedic appointment, A and E staff stepping around elderly sick patients sitting on hard chairs for hours on end in corridors.
Dr Joss Bray: Yes - I hope the Competent Compassion checkups will help people and organisations to develop these skills by identifying needs. And certainly Competent Compassion needs to be a core ethos within organisations.
Q. Why are drug and alcohol services so professionally stigmatised when addiction is known to be a complex and chronic health condition?
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Dr Hugh Gallaher: It may to a large extent be the fault of Drug and Alcohol Services in not meeting and engaging sufficiently with medical and other colleagues, informing and educating and offering more shared care.
Dr Bern Hard: It’s embedded in our culture. It is also true of obesity for example. My view is that this affects conditions where ‘behaviour’ that we have a conscious sense of agency about is affected. I find it hard to demonstrate free will anywhere, but I do feel we have agency, and this would be a conscious awareness of the thought and feelings processes leading up to a behaviour that we would consider a ‘choice’.
Where we fight for autonomy, and a right to make choices, society then tends to apply a degree of moral responsibility for the consequences of these choices. We want to live in a free society, where we can drink a litre of vodka if we choose, and eat a bar of chocolate. People don’t want to live in a state where the government mandates these aspects of their lives, but then when the predictable consequences occur, does choice become illness?
In the case of addiction, where there are clear biological markers suggesting a pathological process (genetics/ alteration in brain structure and function) which support an illness model, this is then sometimes undermined by a confusion between using illness related language and stigma. We have moved away from ‘patient’ over the last decade, preferring all kinds of clunky alternatives like ‘people who use our services’. If we are not prepared to call people patients, how can we blame the public for failing to see addiction as a chronic health problem?
Dr Joss Bray: Perhaps because people look down on those with SM problems and think they have brought it on themselves - therefore don’t deserve treatment. Perhaps professionals are scared of these patients. Perhaps people think nothing can be done.
Q. As a sector could we use more MDT approaches to present prescribing as a 'service decision', rather than a 'sole prescriber' to stop individuals being 'blamed' for prescribing decisions?
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Dr Hugh Gallaher: MDTs certainly are important in developing cohesion within teams and establishing a common ethos but must operate on a non-hierarchical basis.
Effective rehabilitation/recovery will not be achieved by prescribing alone. Initiation and alteration of prescribing should always follow communication or involve prompt communication with colleagues. 3-way meetings between prescriber, patient and keyworker/caseworker/counsellor/nurse/social worker is an extremely useful method of eliminating the issue of sole responsibility for the part played by all constituent members.
Dr Bern Hard: Yes definitely, but there is a staffing cost to this. My experience of third sector is that doctors are viewed as a necessary nuisance and best, very costly. And their hours are to be kept to a minimum and used in the most efficient manner. That does not stretch to funding them to sit about discussing clinical decisions with the team. Also, there is more and more emphasis on speed. Getting a script the same day as you present for example. There are benefits to this, but it limits the opportunity for reflection and discussion.
Dr Joss Bray: Yes but this could be used as a cop out for professional decision making and is time consuming. However - we do use them for complex issues and blaming "NICE" or the "guidelines" can be useful to divert wrath from frontline staff.
Q. How do we marry the two points of view - the need (for) competent compassion in frontline staff AND that we also are not scapegoating frontline staff?
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Dr Bern Hard: We need to stop using front line staff to fire managerial bullets. Many times, clinicians are highly competent but are not able to deliver the care they know is evidence based due to resource issues. This not only hurts them as they are compassionate, but it causes moral injury.
Plenty of times I have had a strong desire to help the patient (compassion) I am perfectly competent (understand the evidence base) and yet I must tell the patient we can’t give XYZ as there are no treatment spaces.
Dr Joss Bray: Very important issue - that’s why we need Competent Compassion as an organisation wide ethos.
Q. Unfortunately many staff had experienced what you went through and sadly this is still the case in the NHS and third sector. I worked in the NHS at senior management both as a service director and senior commissioner for over 30 yrs and have witnessed the experiences which you described. We talked a lot about holistic approaches, user involvements, etc, yet we are still a number crunching orientated NHS and perhaps become too much of a penpusher workforce culture. With AI, we are more likely to become a dehumanised society. People with mental health and PWUDS if anything as a result of their help-seeking behaviours, in my book need more of a human touch approach which I agree with the two speakers.
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Dr Bern Hard: Agreed. At its heart addiction is a failure in healthy human connection. Meaningful treatment needs therapeutic relationships where healthy connections can be established.
Dr Joss Bray: Very important issue – that’s why we need Competent Compassion as an organisation wide ethos.
Q. I'm writing my dissertation about stigma for service users who use substances. Do you think terms that healthcare workers use can add to the stigma? for example, if we say 'people who use drugs' instead of addiction, would that help?
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Dr Hugh Gallaher: I recently attended a meeting where a non-clinical person, on hearing the term Alcohol Use Disorder, thought the term was derogatory. I stated that it is the current term in vogue but will likely be replaced within 10 years. Language and terminology can certainly add to the stigma but I feel that the manner of communication has far greater potential to induce or reduce stigma. This requires training for all individuals, all disciplines working in the field.
Dr Bern Hard: No. I think the words we use are largely a distraction. If you have a decent longstanding human connection, based on trust and understanding, what phrases you use are of secondary importance. Sure, derogatory terms like ‘junkie’ and ‘smackhead’ are unacceptable and dehumanising. But I hardly ever hear these from HCP’s. I hear the service user community describing themselves and their companions in this manner far more often.
And as already stated, using language which is accurate in describing an illness is not stigmatising. It is more problematic to use language which appears to contradict an illness model, as it places more responsibility for behaviour on the patient.
Dr Joss Bray: I am wary of changing terms because someone may be offended - just use the most descriptive one - it will change next year anyway!
Q. Do you think that the NHS 10 year workforce strategy that seeks to embed trauma informed practice and increase the proportion of registered profs working in drug services will help reduce stigma?
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Dr Bern Hard: Probably not. But maybe I have reached the cynical stage of life :)
Q.Very interesting webinar, do the panel feel supervision is important for the case workers or for themselves, within their profession? Not heard supervision mentioned to monitor competence, compassion, stigma as discussed?
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Dr Hugh Gallaher: Supervision is a vital element, not at all optional, for safe and effective case working and healthy caseworkers. Perhaps ((it) should be mandatory also for Doctors. Having treated many caseworkers and other professionals, including Doctors, who have relapsed while working in services, the standout reason is non-existent or wholly inadequate supervision (as well as ceasing attendance at peer support meetings).
Dr Bern Hard: Yes I think good quality psychological supervision is invaluable. To have a space where we can talk honestly and openly and let our own feelings emerge uncensored is very powerful.
Dr Joss Bray: Yes supervision could reflect on the feedback from the Competent Compassion checkups in a meaningful way - it would be a very useful tool to do this and to demonstrate it is being done to the CQC, etc.
Q. We are seeing lots of GP practices that refuse to take on acamprosate or nalmafeme prescribing that is initiated by the specialist drug service...we are unsure whether this is caused by stigma in primary care or economic constraints
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Dr Hugh Gallaher: JAMA: Expanding Alcohol Use Disorder Medications in Primary Care [attached]
This article discusses the underuse of medications for alcohol use disorder (MAUD) in primary care despite their proven effectiveness. Nearly 29 million U.S. adults have alcohol use disorder (AUD), but only about 10% receive treatment, and just 1.9% receive MAUD, such as naltrexone, acamprosate, disulfiram, or topiramate. These medications can help reduce alcohol consumption and support recovery, even without complete abstinence.
Barriers to MAUD use in primary care include a lack of routine AUD screening, stigma among both clinicians and patients, clinicians' unfamiliarity with MAUD, and time constraints in medical visits. Many primary care doctors also mistakenly believe these medications are not effective. However, when comparing their number needed to treat (NNT) with other commonly prescribed medications, MAUD perform similarly or better—for example, oral naltrexone has an NNT of 11, which is comparable to medications for depression and diabetes.
To improve AUD treatment, primary care clinicians should routinely discuss MAUD with patients and prescribe it as part of a stepped-care approach, similar to treatments for conditions like asthma or cardiovascular disease. Efforts to increase MAUD use should focus on clinician education, systematic screening for unhealthy alcohol use, and reimbursement for collaborative care models.
Addressing misconceptions about MAUD efficacy is crucial to integrating these medications into primary care and reducing the public health burden of alcohol-related harm.
Dr Bern Hard: As a GP and someone who has worked in specialised services, I think this is a simply a reflection of a GP workforce that is way past breaking point and can’t cope with any more stuff being dumped on them by secondary care services.
Dr Joss Bray: I am guessing that it is a mixture of being overworked, feeling put upon, lack of understanding of the drugs and concepts and generally wanting money for "extra" work done. However - people with SM problems have been identified as a vulnerable group and should receive these services as a priority.
Q. How do we move away from this idea of addiction as a 'Disease of the Will' that lodges understanding in the deserving / underserving paradigm
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Dr Bern Hard: Go with the science. Drop the narrative of de-medicalisation. The neuroscience points to a disorder in brain reward, learning and memory circuitry. Some aspects of the service user movement that have attempted to reject the illness label have resulted in natural shift towards this being a lifestyle choice, and therefore less deserving of compassion.
Dr Joss Bray: Imagine you or a close relative or dear friend end up addicted to drugs or alcohol - what help would you want for them? That usually changes perceptions of "deserving".
Q. How do you feel integrated working, as in 'all under one roof' as opposed to working as silo services, improve and/or break down stigma?
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Dr Hugh Gallaher: Integrated working is an essential requirement for successful outcomes and fulfilling work but requires careful communication to establish those working relationships and to counter the fears and anxieties around threat and exposure. It has to be sold as a means of easing the work, improving the outcomes and making work and life in general more satisfying and must achieve those lofty ambitions in order to be maintained.
Dr Bern Hard: I am not sure which services are being considered here. Certainly it can help to have a better understanding of each other’s roles, as this can lead to increased tolerance.
Get in touch with us on ideas for future webinars, please email: info@antistigmanetwork.org.uk