“If they are not motivated, then we can’t help them”: aspects of professional stigmatization in dual diagnosis
- Katrine Schepelern Johansen
- 2 days ago
- 4 min read
Stigmatization of psychiatric patients, particularly those with co-occurring substance use disorders, is a common reason for exclusion from both society and treatment within the Danish healthcare system. Healthcare professionals are generally aware of this problem and are often able to identify the consequences of societal stigmatization, such as prejudice, exclusion from treatment, judgmental questioning, and unwarranted assumptions. However, institutional logics, professional identity and pride, and triage practices may also contribute to stigmatizing practices within the psychiatric treatment system itself.
Recent studies following the implementation of integrated dual diagnosis treatment in regional psychiatry in Denmark have suggested that forms of professional stigmatization may obstruct adequate treatment and create confusion within the psychiatric treatment system. In this commentary, we outline some of the underlying factors that may help explain the professional stigmatization observed in this context.
Stigmatization?
The concept of stigma originates in sociology, and the American sociologist Erving Goffman is widely regarded as one of the foundational figures in this field. Put simply, stigmatization is a process in which one specific characteristic of an individual comes to dominate how others perceive and interact with that person. In cases of stigmatization, that characteristic is typically perceived negatively by the surrounding society. Stigmatization often serves to justify limiting access to desirable resources.
As with many other sociological concepts, such as power, stigmatization can be understood as a mode of perception embedded in human interaction more broadly. In that sense, all people engage in stigmatizing processes to some extent. However, when stigmatization occurs within treatment settings and has serious consequences for those being stigmatized, healthcare professionals have a responsibility to remain aware of it and to seek alternative ways of understanding and responding to patients.
Substance use and the psychiatric treatment system
The scientific foundations of psychiatry as a medical specialty, as well as the nature of psychiatric disorder itself, have long been subjects of debate, particularly since the field emerged in its modern form in the late nineteenth century. Questions such as whether psychiatric symptoms can be understood in the same way as symptoms in other medical specialties, or whether psychiatry should be replaced by broader and more inclusive frameworks, continue to be discussed. These debates are often driven by psychologists and sociologists outside the hospital system and tend to center on people in recovery or those with relatively mild psychiatric difficulties, such as late-diagnosed attention disorders or anxiety.
However, many patients with dual diagnosis face far more complex challenges, including somatic complications, financial hardship, insufficient pharmacological and non-pharmacological treatment, delayed assessment, and repeated interruptions or terminations of planned care. For these patients, psychiatric expertise and medical support are central to treatment, not least to ensure survival during periods of escalating substance use. Patients with dual diagnosis constitute a substantial proportion of the psychiatric population as a whole—up to 50–70% in some settings—so this is by no means a marginal group.
Dual diagnosis and the professional background for stigmatization
The fluctuating nature of both psychiatric symptoms and substance use appears to amplify the vulnerabilities associated with being a patient in a hospital system. If a patient is unable to attend consistently or engage in a stable manner, there is a risk of being discharged from treatment and labeled as “untreatable.”
This narrative persists as an embedded logic within the psychiatric system, sustained in part by the triage practices that hospital work necessarily requires: can this patient wait, or is the situation already too severe? Is this our responsibility, or does it belong elsewhere? Complexity is often difficult to categorize and place appropriately within institutional structures, and this is especially true for patients with co-occurring conditions or those who are perceived as noncompliant.
Staff rarely state openly that they do not view such patients as deserving of treatment. Instead, this position is often expressed through euphemistic formulations: we cannot help him if he is not motivated; he would be better placed in another setting; he is not benefiting from treatment; all treatment options have been exhausted; or the patient is not-therapy-ready. These formulations differ in wording, but they point in the same direction: that the patient should not be here, not now, and is not the responsibility of this service.
As a result, a discourse has emerged in which the patient with dual diagnosis is constructed as fundamentally un-helpable: as someone who is “untreatable” and must qualify for treatment before being allowed to enter it. In practice, this often means having to “prove” engagement—for example, by expressing a strong desire to stop using substances or by adhering to the planned treatment trajectory—while staff may respond with disappointment when the patient is not capable of doing so.
Closing remarks
To summarize, staff across professional groups working in Danish psychiatry have faced substantial challenges during the implementation of integrated dual diagnosis treatment in Denmark. These challenges relate not only to a lack of appropriate tools and methodologies, including certain psychotherapeutic approaches, but also to the professional identity and pride associated with delivering evidence-based treatment to patients with severe psychiatric disorder. In wider society, stigmatization of people with substance use problems is often rooted in lack of knowledge, fear, or prejudice, as indicated, for example, in studies by the Danish Council for Socially Marginalized People. By contrast, the stigmatization encountered by patients with dual diagnosis within the psychiatric treatment system appears to be more closely related to frustration with the patient, the limited effectiveness of interventions that would usually be expected to work, and the institutional practice of triage.
The consequence of this stigmatization is that a severely ill and vulnerable group of patients may be denied access to the psychiatric care and treatment routinely offered to other patient groups. In an older American study on the stigmatization of men with dual diagnosis, the authors recommended an explicit focus on stigmatization when planning treatment and support for this patient group. Our experience with the implementation of integrated dual diagnosis treatment in Denmark supports that recommendation. □
