Stigmatisation and Barriers to Recovery

1. Stigmatisation and Barriers to Recovery Charlie Lloyd Health Sciences University of York

2. What is stigmatisation? • Stigma = Gk - tattoo or puncture mark – branding • Modern meanings (among others): • ‘a mark or sign of disgrace or discredit’ • Erving Goffman: a discrediting attribute that can make person ‘not quite human’ • Stigma hangs over personal interactions between the stigmatised and the ‘normal’

3. Other features of stigmatisation • Universal in human (and other?) societies. • Stigmas vary across time and place • Perceived blame crucial: the more responsible, the greater the stigma

4. Who are the ‘stigmatised groups’? • Currently: the mentally ill, the disabled, BME groups. Stigma as an unfair process that needs to be combated • But most stigmatised groups are child murderers, paedophiles, rapists, drug dealers – not described as ‘stigmatised’ • Stigma literature has tended to focus on groups that are perceived as blameless • Important implications for drug users

5. Problem drug users: public attitudes • Dangerous, deceitful, unreliable, unpredictable, hard to talk with and to blame for their predicament • More stigmatised than other groups such as mentally ill • Family members also stigmatised: carry blame for addiction • Small study on empathy for pain – video clips of people experiencing pain, 3 groups – healthy, AIDS thru blood transfusion; AIDS thru idu. Self-reported empathy significantly greater for non idu groups. Matched by levels of brain activity

6. Health professionals • 2 studies of treatment of PDUs in hospital setting (US) • Conflict on pain relief • Hospital staff can be distrustful and judgmental but drug users can be aggressive and manipulative

7. The pharmacy • Unique setting where drug users cannot hide their identity • Half of the users in two UK studies reported feeling stigmatised. • ‘They will make you wait around the corner and serve all other people first…like we are scum.’ • Shop design – separate doors/space – more or less stigmatising?

8. Addiction services • Potential to increase stigmatisation by cementing an ‘addict’ or ‘junkie’ identity. • Can conflict with conventional lifestyle - esp MM • Can lead to further rejection from family and friends • Issues can lead to treatment avoidence

9. Policing • JRF study of 62 users • Contact – coercive, adversarial, ‘unjusified’ • ‘…they’re collaring you and they’re PNCing you and they’re stopping you, and they’re embarrassing you in the street by making you spreadeagle on the car…just trying to belittle you in public...’ • Particularly problematic for ex-users in recovery

10. Impact of stigmatisation • ‘They look down on me as the scum of the earth…’ PDUs often feel profound sense of social rejection and isolation • High self blame; low self-esteem • Study: recognition of facial expressions. 6 basic expressions – happiness, sadness, fear, anger, surprise and disgust. PDUs generally slow – but signif more likely to accurately recognise disgust

11. Stigma as a barrier to recovery • Focus on ‘ex-users’ who must be given chance to ‘reform’ • Discriminated against in employment and accommodation • Majority of employers will not employ someone with history of heroin or crack cocaine use

12. Issues: medicalisation v criminalisation • Medicalisationvscriminalisation • However, a disease with many social origins. Also many diseases stigmatised: leprosy, AIDS… • But criminal perspective more stigmatising. Illegality and ‘war on drugs’ – talking tough

13. Issues: media and language • Media – crucial influence. ‘Junkie’ frequently used word. Invective. • Language important. Study of 728 mental health profs – vignettes – ‘Mr Williams is a substance abuser/has a substance use disorder’ – s.a. group more likely to see him as personally culpable, requiring a punitive response • ‘Drug abuser’ – NIDA, DSM IV. Misleading term – users treat their substances with great devotion. May contribute to stigma.

14. Issues: blame • Lies at heart of the strong stigma attached to PDU • 2 elements: 1) took illicit drugs in first place 2) ‘choose’ to continue to take drugs • But risk factors genetic and early family, so blame? Also users clearly do not feel that they have a choice.

15. What can be done? • Stigmatisation involves complex social interaction between individuals – hard to influence. But… • Protest – user/advocacy groups. Campaign to ban use of ‘junkie’ in the media? Celebrities. • Education and training. Public education on addiction; training for health care, treatment and pharmacy staff, police. • Contact – personal experiences of PDUs in town centres. The Big Issue. Other approaches? Volunteering. • Arnold Schwarzenegger.

16. Conclusions • Stigmatisation matters – felt exquisitely due to deeply social make-up. • Serious impact on lives of those it affects. • PDUs highly stigmatised group • However, unlike disabled and mentally ill, not perceived as a blameless, unfairly stigmatised group • Major aim of those wishing to decrease stigmatisation of PDUs should be to challenge the widespread sense that they have only themselves to blame. • Must be a priority for any Government setting its sights on social reintegration and recovery