Reflective Techniques for Battling Stigma: Mental Health and Addiction Experiential Education

It is much easier for healthcare providers to acquire technical knowledge and skills than it is to develop professional attitudes and empathic capacity for working effectively with people with addiction and mental illness.

This extends beyond healthcare. Professionals from many fields may also struggle to know how to interact with colleagues who may have addiction or mental health issues: even when a colleague’s problem may have been treated and has been stable for years.

Attitudinal factors impact on professionalism, communication, scholarship, and collaboration capacities that in turn affect the treatment received by people with these problems.

The discrimination towards those with addiction and mental health problems has been going on for centuries. Despite it being the 21st century, the addiction and mental health fields continue to be cloaked in various false-beliefs, stigmas, and faulty assumptions. These factors contribute to a failure to understand and respect mental illness and addictive disorders as chronic conditions similar to other medical conditions.

One key way to address stigma is the willingness to explore how one’s own assumptions and biases can construct one’s professional and personal attitudes.

There is evidence that inviting people to think about their attitudes and assumptions helps ground the knowledge and skills that they acquire more effectively i.e. confront and overcome embedded stigmas and stereotypes. The ability to actively reflect allows one to learn experientially in ways that lead to continued professional and personal growth and development.

Instilling, supporting and evoking this professional competency can be explicitly included in the learning experiences that educators and employers construct for their students / staff.

Simulations to use as triggering experiences for discussion are ideal for promoting critical reflection on these issues. I must admit that I lean to designing these types of scenarios over all others – where the goals involve attitudinal and value issues. I believe there is a dearth of these types of scenarios compared to the vast number that focus on specific communication and technical skill sets.

Reflection facilitates the development of increased awareness of deeply held but often unexamined attitudes, values, and beliefs about human problems, how they originate and develop, and how they should be addressed. Our behaviors as professionals implicitly embody, enact, and reveal these fundamental dispositions that people all have. Learning and training that intentionally includes self reflective activities can help individuals become aware of their embedded beliefs. This then allows them to shape their professional behavior more purposively.

This fits the experiential learning cycle described by Kolb who posited that understanding of reality is built upon experiences, which in turn shape ideas about what is valued as knowledge. This is also one of the theoretical frameworks that simulation is based upon.

In fact, it is the debriefing portions of simulations with attitudinal training goals where through the use of reflection, the major learning occurs for the participants.

Strange enough, although it would be obvious when you take a step back and think about it, the same briefing, facilitating and debriefing techniques can be used or adapted for non-simulated experiences i.e. real life encounters! (Well, it should not be strange for educators!)

The key then is to create a structure that supports this approach i.e. a healthy learning climate with psychological, physical and ethical boundaries. It is beyond the scope of this post to describe all the details of creating a constructivist learning climate for sharing discoveries and education. I will share a few brief ideas and components for consideration when building a reflective practice for participants.

TIME AND SPACE

For all educational activities I am involved in, I carve and “infrastructure” into workshops, presentations and course curricula designated time and space for reflective activities. One thing you must realize, just as with simulation, the process requires time and space to allow meaningful reflections. If you do not put time and space in, then you may get some brief surface reflection at best. Usually, people just walk away with simple concrete points without context or depth without the purposeful pursuit of deeper reflection. This is similar to the concept of allocating time for briefing for an event, experiencing the event (real or simulated) and a lion’s share of time for the debriefing of the experience to make sure the educational goals were achieved.

JOURNALING

Capturing reflections can take many forms, such as writing, drawings, thought-maps, voice records, and anything that can create a physical expression of one’s thoughts that can later be reviewed. I provide reflection journals, or add reflection notes to course packages, to ensure a person has been given at least something to jot reflections down.

Some programs demand people reflect on certain subjects or themes and ask for papers that then get graded. I usually tend to informing learners that whatever they wrote in the journals is for their eyes only. For rotations, workshops or full certification programs I have designed, I often do have a formal requirement of asking for a reflection paper at the end of the experience. This helps a person consolidate their learning from the journey he or she underwent. The private journaling helps people track issues and incidents that had happened and would be a resource to draw on for the reflection paper.

INDIVIDUAL REFLECTION TIME

I often help carve out actual time where the learner has “reflection time” where they could read, journal, or working on a reflection paper as desired on his or her own. There was no measurement of how the time was specifically used – honour system is what was used. I believe that if you expect people to do something as part of a training program or professional development, not to ask them to do it on their personal time. If you really believe it is important, then you need to make it core to the education process and not a dubious add-on.

GROUP REFLECTION TIME

It is important to allow group reflections with participants in this process. The goal is to create a safe environment where participants can talk not just about formal technical issues but also about their own perceptions, beliefs, and values. Encouraging and modeling reflective self-disclosure is one task for the mentor to attend to deliberately. The importance of having a group is key for eliciting other points of view, normalizing experiences, and developing professionalism.

Personally, as an educator, I find working with learners in the experiential and reflective spheres amongst the highlights of my work. Many who have engaged in these activities have highly recommended the process to colleagues and friends. 
For many, reflection did not come easy. Some commented they did not really want to write their reflections, but when they began writing they saw the benefit. Many identified the act of self-reflection as leading to recognizing their own biases, which in turn led to cognitive dissonance, and then to a shift in their attitudes toward people with addictions and mental health. This attitudinal shift had an impact on their understanding of the conditions and their actual behavior in dealing with patients. 
By being exposed to people who did not match the stereotypical images people held of “addicts,” and “mental patients” perceptions and attitudes frequently emerged in ways that could be constructively explored.”

Some comments from learner reflection papers (with permission):

“I found myself amazed at the fact; despite his burning desire to quit he was unable to make progress. The impression I had before was that if someone really had the will to quit and the intelligence to make a good plan then they would have little difficulty in abstaining, but clearly I was wrong.” 


“I believe that I will take with me for the rest of my career the understanding that you can never determine someone’s addiction status in a glance.” 


“I feel ashamed about placing more stigma upon this already highly stigmatized population.” 


“I now realize some of these biases could have potentially developed into avoidance of important psychiatric issues and negative countertransference to my patients.”

“Compassion—some patients are very frustrating and attempt to tell lies about their drug use—I need to understand the person’s story.”

“I feel I am more aware of the complex nature of addiction having seen it in medical, psychiatric, and social contexts during the rotation.”

“Foremost I have learned the value of self-reflection through journals, discussion with colleagues and teachers and self-evaluation. Reflection has helped me realize my initial biases about substance abuse and treatment.”

“I have never been the journaling type. . . . I have been pleasantly surprised by how valuable the process seems to be . . . it pushed me toward being more aware of my own thoughts, biases and emotions—an internal dialogue.”

“This rotation introduced me to a very complex aspect of psychiatry. I will no longer gloss over the addiction section of my interview without giving it the respect it deserves for having the ability to worsen mental illness, bring on physical illness, halt productivity, and alter quality of life.”

One striking feature was the presence of comments that went beyond the formal expectations of the activity. This included powerful admissions of self-discovered biases, attitudes, and beliefs. It also meant that on occasion participants used the activity to explore and share issues of addiction and mental health that were close to them personally.

REFLECTIONS – YOUR TURN!

Reflection activities help humanize the understanding of mental health and addiction problems, and enhance the compassionate and empathic under-standing of these problems, which are too often stigmatized and left on the margins in psychiatry as in health care in general.

So go and reflect please!

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