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

2. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 12 Issues: medicalisation v criminalisation Medicalisation vs criminalisation 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. 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. 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. 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. 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