Stigma

1. Stigma Dr. Oliver Aldridge Edinburgh, Midlothian & East Lothian DTTO I and DTTO II

2. Outline • Theory • Client • Communication • Agency • Conclusions

3. Stigma is here to stay • Ancient Greeks physically scarred people to permanently “mark” them • Today: amputation of a finger to denote someone who is deemed to be a “grass” • May be part of the survival mechanism of group living • Some of the original driving force behind drugs legislation – San Francisco 1865

4. Stigma needs to be Managed

5. Why do we stigmatise? • Reciprocity • Threat: housing, benefits, treatment/support, theft, “infecting others” by introducing to drugs. • Downward comparison • Belief in a “Just” world/ “Protestant Work Ethic” – you get what you deserve and you deserve what you get

6. Stereotyping • Drug users are bad parents • Drug users are dishonest • Drug users are manipulative • Drug users are self-indulgent • Drug users are wasters • Drug users destroy communities • Drug users choose to be drug users

7. Linking Stereotyping & Stigmatisation • Stereotyping facilitates stigmatisation • Stigmatisation encourages stereotyping • May be linked to depersonalisation

8. Client

9. Individualise Management • Needs to be openly discussed so that it can be managed on an individual level. • Differing levels of stigma sensitivity between clients • Cannot make automatic assumptions about the effect on a client • Cannot make automatic assumptions about the main sources of stigma

10. Complex Origins of Stigma Usually drug use is only one factor: • Poverty • Poor education • Unemployment • Criminal record • Drug taking • Injecting • Parenting

11. Pre-drug History • Difficult childhood • Learning difficulties • May contribute to feeling excluded • Social acceptance may be sought in a marginalised peer group • As part of that group, drug taking/experimenting may be the norm • Effect of criminalising groups?

12. Managing Stigma • Physical Signs • Treatment Stigmata • Social Stigmata

13. Physical • Visible signs of drug use include:Injection sitesPoor dentitionPoor nutritionAppearing intoxicated/withdrawn • Managing these appropriately may increase the range of options in managing stigma

14. Kenny Rogers • You’ve got to know when to hold ‘em…..Know when to fold ‘em….. • Managing disclosure is a highly individual, situation specific problem • If stigma is not overtly discussed, it is not possible to devise an effective, individualised strategy to deal with it

15. Risk of Entering Treatment • Exposure of a previously, largely hidden level of drug use • Loss of employment • Peer group rejection • Relationship breakdown • Increased intervention e.g. Children & Families • Labelling • Disempowerment • Social Isolation

16. Treatment Associated Stigma • Local vs. Centralised treatment services – pros and cons • Failing to treat people holistically • Perpetuating or increasing stigma in the treatment environment • Recovery = Abstinence • Information sharing vs. “raw data” being communicated to people without specialist knowledge

17. Treatment Options • Some treatment options may feel less stigmatising to the client e.g. DHC vs. Methadone • Treatment needs to have a solid evidence base and be effective and appropriate for the client at that time

19. Supervised Consumption of Methadone • May be stigmatising • Alterations to pharmacy may impact positively • May reduce stigma • Effect is individual and, therefore, policy should allow individual assessment/decision making

20. Testing • Method – supervised urine collection processes • Rationale – is it being done to “catch” people? • What is the context of a result? • May help to combat negative attitudes

21. Social Stigmata • Wraparound care essential • Helping people integrate into new social groups • The role of “ex-user” does not work for everyone

22. Education & Communication

23. As specialist agencies we have a responsibility to provide good quality, objective information to: • Communities • Media • Government • Professionals • Students

24. Aetiology of Addiction • Views/hypotheses may impact on stigmatisation • Is it better to be viewed as someone with a genetically determined problem or as someone with a social problem?

25. Dissonance • Facilitating appropriate contact with people who don’t conform to stereotypical views may catalyse change • Caveat: Stigmatisation may paradoxically be increased by contact with someone who is massively different to the stereotypical view • Does the “exception” prove the “rule”?

26. Agency Stigmatisation

27. Agency • May be stigmatised by the communities in which it works – “NIMBYism” • Workers may need support – e.g. outreach, needle exchange workers • Related professionals/disciplines may stigmatise those who work in this field • We may stigmatise each other by perpetuating false debates e.g. Harm Reduction vs. Abstinence • Funding wars may increase stigmatisation by threatening survival

28. Conclusions • Stigma is here to stay – we have to learn to manage it effectively • Management of stigma has to be individualised • Stigma cannot be dealt with if it’s not openly addressed • Treatment can contribute to stigmatisation: agencies need to consider this in service planning/delivery • Commissioning needs to look at the range of treatment services available to increase choice • Agencies have to play a positive role in educating/communicating