Internalized Stigma and Clinical Harm Reduction

1. Internalized Stigma and Clinical Harm Reduction Sheila Vakharia, LMSW Florida International University Housing Works, Inc. sheila.vakharia@gmail.com

2. Stigmatization – Definition • “Stigmatization is entirely contingent on access to social, economic and political power that allows • the identification of differentness, • the constructionof stereotypes, • the separationof labeled persons into distinct categories and • the full execution of disapproval, rejection, exclusion, and discrimination” Link & Phelan, 2001

3. The Public Stigma of Addiction:Current Research (and what we already know) • Attributing responsibility and blame onto users for their problems(Corrigan, Kuwabara & O’Shaughnessy, 2009) • Criminalization of illicit substance possession and/or use(Cross, Johnson, Davis & Liberty, 2001; Lee & Rasinski, 2005) • Association with violence and danger(Rasinski, Woll & Cooke, 2005; Corrigan et al. 2009) • “Drug-free” work environments and mandatory drug screening(Macdonald, Hall, Roman, Stockwell, Coghlan & Nesvaag, 2010) • Mandated abstinence-oriented substance abuse treatment by criminal justice system, child protective services, social services, etc. (Radcliffe & Stevens, 2008) • Negative portrayal in the news and media(Corrigan, Watson, Gracia, Slopen, Rasinski & Hall, 2005)

4. Individual Reactions to Stigmatization • Being energized by it – • Experience what some call “righteous anger” and use it to fuel advocacy, protest and other empowerment activities • Also known as “stigma resistance” or “stigma reactance” • Turning a negative into a positive • Some studies of members from some stigmatized groups that actually have higher self-esteem than majority group members Corrigan & Watson, 2002

5. Individual Reactions to Stigmatization • Neutrality or indifference – • an awareness of the stigma, but no personalization or net impact • Some studies which have shown that members of some stigmatized groups have equal self-esteem when compared to majority group members • Developing self-stigma – • Stigmatized individuals “living in a culture steeped in stigmatizing images, may accept these notions and suffer diminished self-esteem and self-efficacy as a result” Corrigan & Watson, 2002

6. What mediates these different responses? 1. Six domains of stigma (Jones et al., 1984) • Concealability – Hidden or obvious? Is visibility controllable? • Course – Pattern of change over time. Ultimate outcome? • Disruptiveness – Block/hamper interaction/communication? • Aesthetic qualities – To what extent is it repellant, ugly? • Origin – Where did it come from? Who responsible? Why? • Peril – What kind of danger is posed? How imminent? 2. Individual “contingencies of self-worth” (Crocker & Wolfe, 2001) “A domain or category of outcomes on which a person has staked his/her self-esteem” • Examples – Approval, appearance, family support, competency, competition, God’s love, virtue

7. What mediates these different responses? 3. Social cognitive model (Watson & River, 2005) • Incorporated contributions of Crocker (2001) and added “perceived legitimacy” and “group identification” • Low/high levels of PL and Low/high levels of GI predict responses to stigma 4.Self-stigma components (Corrigan, Watson & Barr, 2006) • Stigma Awareness • Stigma Agreement • Self-concurrence • Self-Esteem Decrement

8. Brief Summary Before Moving on… • Stigma does not impact every member of a stigmatized group • If it does, does not affect them all in the same way and may affect them for different reasons • Self-stigma is not necessarily a fixed “trait,” can be fluid and influenced by situations • LIMITATION: There is no specific theory about the particular impact of stigma on drug-using populations, rather, we must apply pre-existing theories based on other stigmatized groups.

9. The Self-Stigma of Addiction:Current Research (and there’s not much) • Lower self-esteem and self-efficacy (Link & Phelan, 2001) • Negative attitudes about drug treatment and early treatment drop-out (Radcliffe & Stevens, 2008) • Mistrust of providers and low satisfaction (Conner, Rosen, Wexle & Brown, 2010; Conner & Rosen, 2008) • Continued substance use and negative beliefs about recovery (Boeri, 2004) • Deviant identity development (Copes, Hochstetler & Williams, 2008; Rodner, 2005) • Limits meaningful interpersonal relationships (Mateu-Gelabert, Maslow, Flom, Sandoval, Bolvard & Friedman, 2005) • Judgment and mistrust of other users (Simmonds & Coomber, 2009; Rodner, 2005)

10. How does it look in Clinical Practice? • Client’s use of language: “clean,” “dirty,” “strong,” “weak” • Client’s use of labels: “crackhead,” “junkie,” “drunk” • Underreporting or not reporting current drug use/ risk behaviors • Shame • Guilt • Limiting oneself from pursuing opportunities • Transference and projection onto provider • NOTE* Can be mistaken for symptoms of co-occurring mental illness, but also vice versa

11. Treatment Approaches:(not a lot of empirical evidence) • Engaging in empowerment and advocacy activities • Brief interventions have mixed results • Psychoanalysis, long-term therapies • Cognitive therapy to address schemas – contingencies of self-worth, perceived legitimacy, stigma agreement and self-concurrence • But then are we being complicit to public stigma?

12. Importance of having the discussion • There is still not enough research about the actual experiences of self-stigma from the perspective of drug users themselves • Limited intervention options for CBOs • Need for more research • Until then, we can learn from lessons of the theoretical literature and begin to write about what is working for us with our populations…

13. Thank you!