Approach to limiting bias for patients with Mental Health and Substance Use Disorders

By Megan Pinder, PA-C

Stigma and bias can lead to poor patient outcomes for people who have mental health and substance use disorders. So, what can providers do to help patients and limit their barriers to receiving high-quality care? Being aware of bias/stigma and how these can manifest is a great first step. Here, we will explore some ways to mitigate bias and stigma in the healthcare setting.

I. Mitigating structural bias and stigma

Structural bias and stigma can be difficult to approach as this type of stigma occurs at the macro level. However, understanding where these biases may manifest as barriers to care can help providers anticipate the resources that patients may need to have better access to care. For example, a patient may have limitations regarding treatment services based on their insurance type or lack of insurance. Understanding this can help a provider look for alternative options, such as state-funded treatment facilities for patients without insurance. It could also help providers anticipate the feasibility of treatment based on affordability. Finding ways to help patients obtain medications in a cost-effective way through various programs can help increase the likelihood of adherence to the treatment plan.

Another way to help with structural bias is to review hospital policies and practices that may contribute to stigma or bias. By implementing a structured evaluation process to identify bias and stigma, and prioritizing evidence-based quality improvement initiatives to address these issues for patients, we can work toward a more equitable and inclusive healthcare system.

Another approach to helping with structural stigma is to integrate patients into community-based care. The World Health Organization recommends this to help patients function without isolation. (2, 3) One way to achieve this goal successfully is to provide resources for their level of need in the community setting. Examples include peer support services and assertive community treatment team services. Peer support is used in both substance use disorder treatment and mental health treatment to connect people in varying stages of recovery with people who share similar experiences. Assertive Community Treatment is an evidence-based practice that offers treatment, rehabilitation, and community integration to people with serious mental illness. It is typically comprised of a mental health provider, nurses, therapists, and other mental health professionals who help with different aspects of a patient’s community-based care. Making community-based resources available to patients can help decrease the need for institutionalized care, which can be stigmatizing. (2)

Fragmentation of care can be a barrier that prevents patients from receiving high-quality care.  By increasing collaboration between different providers, patients can have better outcomes. Effective collaboration can help mitigate instances of diagnostic overshadowing. Also, having mental health services integrated into general healthcare or into other social sectors, such as school or work, can help increase access to care. One source suggested that combining appointments for physical and mental health care can help patients to better manage their overall health. (1, 2)

II. Mitigating explicit bias, cognitive bias, and interpersonal factors

Studies on explicit bias have shown that more exposure to patients in a particular group can result in providers having more positive attitudes. (37,42) For example, professionals who have more personal or work experience with patients who have substance use disorders (i.e. mental health providers and addiction specialists) were more likely to report positive explicit attitudes towards this patient population. (31) Much of the bias and stigma research on many stigmatizing diagnoses have shown similar trends. For example, interventions combining more education about the disorder and treatment with meaningful interpersonal exposure to patients who had borderline personality disorder were most effective in decreasing stigma. (6) For this reason, education is essential in helping with not only initially shaping the views of new providers, but is also an important aspect of continuing education of established providers. Seeking out education opportunities such as Mental Health First Aid training, education about recommendations and treatment options for substance use disorders/mental health disorders, and taking time to learn more about a particular diagnosis can help reduce the associated stigma.

As we previously discussed, many providers who do not express explicit bias are unaware of the ways they may affect the care that they give patients due to cognitive bias and implicit bias. To combat this, one must understand factors that may increase the chances of relying on heuristics (mental shortcuts) in the approach to patient care. Doing so may help to limit cognitive bias and interpersonal stigma.

One such factor that can lead to cognitive bias is increased cognitive load. (1, 7, 8) Cognitive load is the amount of information our working memory can process at a given time. This can be increased by environmental factors, competing mental tasks, one’s psychological/physiological state, and finally, the actual task a provider is trying to complete. Caring for patients carries a lot of cognitive load for many providers. Finding ways to decrease that cognitive load can help. Mindfulness training and stress management can decrease anxiety and stress related to work. (7) The following list includes additional opportunities to decrease cognitive load and mitigate cognitive bias:

Time constraints

Sometimes, time constraints can cause providers to rely more heavily on using mental shortcuts than structured processes, which may take longer to employ. (1) By giving adequate time for decision-making, one can reduce the likelihood of using heuristics in reasoning. Unfortunately, sometimes time constraints are not so easy to control when they are built into work structures. However, advocating for work practice changes like time buffers throughout the day could be a helpful compromise.

Cognitive Aids

Utilizing cognitive aids such as algorithms, checklists, and techniques to emphasize a more structured process can decrease cognitive load and help maintain structure in decision-making. (6,38) Using and becoming familiar with algorithms and clinical practice guidelines can help to ensure that providers are using a similar cognitive process with all patients. For example, in an algorithm designed to approach a patient with signs of psychosis, there may be a prompt to rule out substance use disorder or a medical condition (which aligns with DSM criteria for diagnosing primary issues with psychosis). This reminder is a way for providers to check that they are meeting the full criteria and completing and appropriate diagnostic work-up. The use of algorithms in combination with the appropriate use of screening tools for mental health conditions can help to decrease the incidence of diagnostic overshadowing.

Self-reflection

Metacognition involves having a self-reflective approach to problem-solving. It is a way to reflect on one’s thinking process. One problem with utilizing metacognition is that it may take more time to go through this process. As discussed previously, more time can help with clinical decision-making. However, in high-stress, fast-paced environments (like the emergency department), it can be counterintuitive. Having a quick way to tap into metacognition could be helpful in these settings. There have been studies that explore utilizing tools such as mnemonics to help with this. (9)

III. Mitigating Intrapersonal stigma

Intrapersonal stigma is another barrier to care that can limit patients with mental health and substance use disorders. Intrapersonal stigma can be influenced by other types of stigma. Therefore, some of the debiasing strategies previously discussed may also help here. Another factor to consider, however, is the perception of the patient. Do they feel comfortable or accepted seeking care from healthcare providers? This can be a driving factor for whether they choose to seek care in the first place.

One way to help patients feel accepted is by using active and empathetic listening strategies. The way we listen to patients can greatly influence how they perceive an encounter. With active listening, the listener checks to confirm understanding. Examples of ways to utilize active listening include:

  • Remaining neutral and non-judgmental
  • Getting rid of distractions
  • Use of verbal and non-verbal signs that you are listening
  • Asking questions that reflect back what is said

Empathetic listening is similar to active listening. Both employ verbal and non-verbal cues to help convey a message to the patient. However, with empathetic listening, the focus is on the emotion a patient feels. Sometimes this term is used interchangeably with therapeutic listening.

A second way to help patients feel more comfortable is to use patient-centered language in front of patients and around other providers. Patient-centered language helps to put the patient first and reduce the urge to define them as their diagnosis. It can help remind both the patient and provider to view a diagnosis more objectively. An example of this is using phrasing like “a person with a mental illness” rather than “a mentally ill person.” Other examples of patient-centered language are as follows:

  • A person with schizophrenia vs. schizophrenic
  • A person with a substance use disorder vs. an addict

Using stigma-free language can help limit bias transferred in the medical record to other providers. Changing the language used is a tangible way to not only help patients feel more accepted but also to change how other providers view people with mental health and substance use disorders. Stigmatizing language can result in readers viewing a patient more negatively, whereas non-stigmatizing language can have the opposite effect. (11, 12) Some examples of non-stigmatizing language are as follows:(10)

  • Drug abuser vs. a person with a substance use disorder
  • Dirty urine drug screen vs. positive urine drug screen
  • Relapse vs. return to use
  • Clean/sober vs. in remission

Remember, the first step to mitigating bias is to recognize that we are all susceptible to bias. In the last article, we outlined types of bias and ways to recognize this bias in clinical care. Now, with these new tools to mitigate bias, we can start looking within ourselves and our institutions to make meaningful change so that our patients can have better outcomes.

Works Cited:
  1. [6] Hallyburton, A., & Allison-Jones, L. (2023). Mental health bias in physical care: An integrative review of the literature.Journal of Psychiatric and Mental Health Nursing30(4), 649-662.
  2. [36] Knaak, S., Livingston, J., Stuart, H., Ungar, T. Combating Mental Illness- and Substance Use-Related Structural Stigma in Health Care: A Framework for Action. Mental Health Commission of Canada. [literature review]
  3. [37] WHO: https://iris.who.int/bitstream/handle/10665/356119/9789240049338-eng.pdf?sequence=1
  4. [42] Raj CT. The effectiveness of mental health disorder stigma-reducing interventions in the healthcare setting: An integrative review. Arch Psychiatr Nurs. 2022 Aug;39:73-83. doi: 10.1016/j.apnu.2022.03.005. Epub 2022 Mar 24. PMID: 35688548.
  5. [31] van Boekel LC, Brouwers EP, van Weeghel J, Garretsen HF. Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review. Drug Alcohol Depend. 2013 Jul 1;131(1-2):23-35. doi: 10.1016/j.drugalcdep.2013.02.018. Epub 2013 Mar 13. PMID: 23490450.
  6. [28] Sheehan L, Nieweglowski K, Corrigan P. The Stigma of Personality Disorders. Curr Psychiatry Rep. 2016 Jan;18(1):11. doi: 10.1007/s11920-015-0654-1. PMID: 26780206.
  7. [38] Knaak, S., Mantler, E., & Szeto, A. (2017). Mental illness-related stigma in healthcare: Barriers to access and care and evidence-based solutions. Healthcare Management Forum30(2), 111-116. https://doi.org/10.1177/0840470416679413
  8. [39] Are Providers More Likely to Contribute to Healthcare Disparities Under High Levels of Cognitive Load?: Ncbi.nlm.nih.gov/pmc/articles/PMC3988900
  9. [43] Henderson C, Noblett J, Parke H, Clement S, Caffrey A, Gale-Grant O, Schulze B, Druss B, Thornicroft G. Mental health-related stigma in health care and mental health-care settings. Lancet Psychiatry. 2014 Nov;1(6):467-82. doi: 10.1016/S2215-0366(14)00023-6. Epub 2014 Nov 5. PMID: 26361202.
  10. [46] Kelly, J, Westerhoff, C; Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms https://www.sciencedirect.com/science/article/abs/pii/S0955395909001546?via%3Dihub
  11. [44] Chew, K. S., & Durning, S. J. (2016). Teaching metacognition in clinical decision-making using a novel mnemonic checklist: An exploratory study.Singapore Medical Journal57(12), 694-700. https://doi.org/10.11622/smedj.2016015
  12. [45] Volkow, N, Gordon, J, Koob, G; Choosing appropriate language to reduce the stigma around mental illness and substance use disorders

 

Megan Pinder graduated from the Wake Forest Department of PA Studies in 2017. Since that time, she has worked as a practicing PA in multiple psychiatry settings. She is currently on faculty at the Wake Forest PA program and works for an outpatient psychiatry clinic in Winston-Salem, North Carolina.