What does stigma mean to me? · or acts of physical or emotional abuse (towards an individual’s real or perceived identity or membership to a stigmatized group) • Institutional

What does stigma mean to me?

• Prejudicial view

caused by lack of or

incomplete knowledge

• A barrier to seeking

help

• Not getting the help

you need

• Harm

• Negative association

• Access barrier

• Stigma kills

• Barriers

• Deterrent to get help

• Limits opportunities

• Judgmental

• Keeps people unwell

• Marginalization

• Adversity

• Shame

• Judgment

• Not getting the best

care

• Fear of the unknown

• Desire to feel superior

• Discomfort/fear from

others

• Discrimination

• Othering

• Labelling &

pathologizing

• Stereotypes

• Discrimination

• Not letting me reach

my potential

• Hindrance to recovery

• Judgment

• Negative label

• Shame

• Exclusion

• Being defined by

illness and looked

down on because of it

• Fear

• Lack of awareness

• Pain & heartbreak

• Negative views of

marginalized groups

• Stereotype

• Misconceptions

• Bias

• Generalization

• Barrier to supports

• Label (boxed in)

• A form of

discrimination

• Ignorance & judgment

• Judgment & shame

• Negative labelilng

• Stereotypes

• Judgment

What does stigma mean to me?

(Participant responses)

FRANK WELSH, PhD

MAY 27, 2019

STIGMA and structural violence

4

WHAT IS STIGMA?

A mark of disgrace associated with a particular circumstance, quality, or person.

Oxford English Dictionary

… a dynamic multidimensional, multilevel phenomenon that occurs at three levels of society—structural (laws, regulations, policies), public (attitudes, beliefs, and behaviors of individuals and groups), and self-stigma (internalized negative stereotypes). A hallmark of stigma, like stereotyping, is that it overgeneralizes.

https://www.ncbi.nlm.nih.gov/books/NBK384913/#sec_000009

5

STIGMA: A CONCEPTUAL

MODEL

6

STIGMA: A CONCEPTUAL MODEL• Internalized stigma: an individual’s acceptance of negative beliefs,

views and feelings towards themselves and the stigmatized group to which they belong

• Perceived stigma: awareness of negative societal attitudes, fear of discrimination and feelings of shame

• Enacted stigma: encompasses acts of discrimination, such as exclusion or acts of physical or emotional abuse (towards an individual’s real or perceived identity or membership to a stigmatized group)

• Institutional or structural stigma: stigmatization of a group of people through the implementation of policy and procedures

• Layered or compounded stigma: refers to a person holding more than one stigmatized identity

7

CONSEQUENCES OF STIGMA

▪ Structural stigma

▪ Public stigma

▪ Self-stigma

8

EFFECTS OF STIGMA▪ On individuals

▪ Attitudes towards stigmatized individuals

▪ Social impact

▪ Economic impact

▪ Manifest at the systemic, community, and individual levels

9

WHAT IS STRUCTURAL VIOLENCE?“Structural violence is one way of describing social arrangements that put individuals and populations in harm’s way…These arrangements are structural because they are embedded in the political and economic organization of our social world; they are violent because they cause injury to people.”

Dr. Paul Farmer

“Structural violence refers to systematic ways in which social structures harm or otherwise disadvantage individuals. Structural violence is subtle, often invisible, and often has no one specific person who can (or will) be held responsible (in contrast to behavioral violence).”

Adam Burtlestructuralviolence.org

10

PERSPECTIVE

Direct Violence

Structural Violence

11

STRUCTURAL VIOLENCE AND HEALTH INEQUALITY

Social Justice Policies

Structural Violence

Racism

Social Class

Heteronormativity

Individual Social Position

Neighbourhood Context

Neighbourhood

Processes

Individual

Processes

Health Inequality

12

RACE, ETHNICITY, AND GENDER

• Racial profiling

• Disparities in treatment and outcomes based on race, ethnicity, or gender

• Decrease in quality of health and limit in access to programs

@CCSA.CCDUS

@CCSAcanada • @CCDUScanada

Can Centre on Substance Use and Addiction / Centre

can sur les dépendances et l’usage de substances

www.ccsa.ca • www.ccdus.ca

Stigma: Language and Policy

AMHO Annual Conference, 2019

Rebecca Jesseman

May 27, 2019

About CCSA

• Vision: A healthier Canadian society where

evidence transforms approaches to substance use.

• Mission: To address issues of substance use in

Canada by providing national leadership and

harnessing the power of evidence to generate

coordinated action.

• National non-profit organization with a pan-

Canadian and international role.

15www.ccsa.ca • www.ccdus.ca

Strategic Core Functions

16www.ccsa.ca • www.ccdus.ca

Words Matter

What Do You Think Of?

What Do You Think Of?

What Do You Think Of?

www.ccsa.ca • www.cclt.ca

Stigma is the most

frequently reported barrier

to accessing treatment for

substance use

#1

21

Impact

Using Accurate Terminology

• Substance Use

– Use of any psychoactive substance

• Substance Use Disorder

– Clinical diagnosis

– Cluster of cognitive, behavioural and physiological

symptoms

– Specific to substance and level of severity

www.ccsa.ca • www.ccdus.ca 22

Using Accurate Terminology

• Addiction

– Compulsive use despite harmful consequences

(outdated)

• Dependence

– Physiological disorder developed after

prolonged use

www.ccsa.ca • www.ccdus.ca 23

• Put the person first

• Be technically accurate

• Consider associations

– Clean vs. not currently using substances

– Black market vs. illegal market

Terminology: Key Messages

Stigma and Policy

International Treaties

GovernmentLegislation

Professional Policies & Regulations

Workforce Policy & Practice

What Is Policy?

www.ccsa.ca • www.ccdus.ca 27

Making Policy

The Policy Cycle

Agenda Setting

Policy Formulation

Decision Making

Policy Legitimation

Policy Implemen-

tation

Policy Evaluation

Politics

ProblemsSolutions

www.ccsa.ca • www.ccdus.ca 29

Policy Windows (Kingdon)

Magic Policy Window

Policy Stigma

www.ccsa.ca • www.ccdus.ca 30

Where Does Stigma Fit In?

Policy Stigma

www.ccsa.ca • www.ccdus.ca 31

Where Does Stigma Fit In?

Case Study: Opioids

The Policy Cycle

Agenda Setting

Policy Formulation

Decision Making

Policy Legitimation

Policy Implemen-

tation

Policy Evaluation

The Policy Cycle

Agenda Setting

Policy Formulation

Decision Making

Policy Legitimation

Policy Implemen-

tation

Policy Evaluation

• Enforcement

– Increased border security

– Targeting production and supply

• Prescription opioid controls

– De-listing of high-strength opioids

– Prescription monitoring programs

– Prescription guidelines

www.ccsa.ca • www.ccdus.ca 35

Policy Options

• Community-based overdose prevention

– Supervised consumption sites

– Overdose prevention sites

• Opioid-assisted treatment

– Methadone and suboxone

– Diacetylmorphine

• Regulated supply

www.ccsa.ca • www.ccdus.ca 36

Policy Options

The Policy Cycle

Agenda Setting

Policy Formulation

Decision Making

Policy Legitimation

Policy Implemen-

tation

Policy Evaluation

• Politicians

• Media

• The public

• Trusted advisors

• Lobbyists and advocates

www.ccsa.ca • www.ccdus.ca 38

Policy Influencers

The Policy Cycle

Agenda Setting

Policy Formulation

Decision Making

Policy Legitimation

Policy Implemen-

tation

Policy Evaluation

• 2016: Bill C-2: Respect for Communities Act

• 2017: Changes to the Controlled Drugs and

Substances Act

– Streamlining application process for supervised

consumption sites

• 2017: Good Samaritan Drug Overdose Act

• 2018: Regulatory amendments

– Access to diacetylmorphine and methadone

www.ccsa.ca • www.ccdus.ca 40

Legislative Action

• 2017: Canadian Guideline for Opioids for Chronic Non-

Cancer Pain

• 2018: National Guideline for the Clinical Management

of Opioid Use Disorder (CRISM)

• 2018: Federal Emergency Treatment Fund

• Community harm reduction programs

www.ccsa.ca • www.ccdus.ca 41

Additional Policy Action

The Policy Cycle

Agenda Setting

Policy Formulation

Decision Making

Policy Legitimation

Policy Implemen-

tation

Policy Evaluation

• Iatrogenic impacts

– Disempowerment

– Reinforced structural stigma

– Self-fulfilling prophecy

– De-prioritization of structural and social factors

Antoniou, T., Ala-Leppilampi, K, Shearer, D., Parsons, J.A., Tadrous, M., &

Gomes, T. (2019). "Like being put on an ice floe and shoved away": A

qualitative study of the impacts of opioid-related policy changes on people

who take opioids. International Journal of Drug Policy, 66, 15–22.

www.ccsa.ca • www.ccdus.ca 43

Prescription Controls and Stigma

Good Not so Good or Mixed

Increased awareness Divisive dialogue

Inter-sectoral collaboration Community mobilization

Community mobilization Stigmatization within community

Empowerment Politicization

Challenging stereotypes ???

Increased data collection

Increased services

???

www.ccsa.ca • www.ccdus.ca 44

Impacts: Harm Reduction and Stigma

• Involve those most impacted

• Lead by example in language and

practice

• Avoid tunnel vision

• Monitor for iatrogenic results

www.ccsa.ca • www.ccdus.ca 45

What To Do?

UN Commission on Narcotic Drugs

Resolution 61/11

Promoting non-stigmatizing attitudes to ensure

the availability of, access to and delivery of

health, care and social services for drug users.

www.ccsa.ca • www.ccdus.ca 46

International Policy Context

www.ccsa.ca • www.ccdus.ca 47

Cost of substance use in Canada, 2014:

$38.4 billion

Provide Relevant Information

www.ccsa.ca • www.ccdus.ca 48

Break Down Stereotypes!

www.ccsa.ca • www.ccdus.ca 49

CCSA’s Issues of Substance 2019

• CCSA’s Issues of Substance is Canada’s premier

conference for the substance use and addiction field

• Registration now open

• #CCSAConference

Evidence and Perspectives, Compassion and Action.

www.ccsa.ca • www.ccdus.ca 50

Questions and Comments

!?

Contact Information

www.ccsa.ca • www.ccdus.ca 51

Rebecca Jesseman

Director of Policy

Canadian Centre on Substance Use and Addiction

75 Albert Street, Suite 500

Ottawa, ON K1P 5E7

Canada

Tel.: 613-235-4048 ext. 228

rjesseman@ccsa.ca

How have I been impacted by

stigma?

• Not applying for the job

• Hurt

• Developing mental illness like depression

• Lack of services

• Not being able to give clients what they need

• Feeling limited in my choices

• Public: treateddifferently because ofmy height/facialdifference

• Stares, comments

• Internalized: low selfesteem

• Hearing how people view substance use and having a family member who struggles

• Lack of care orcompassion

• Requires increased energy output to advocate and support individuals

• Frustration

• Isolation

• Missed employment opportunity

• Professionally alienated and accused

• Feeling like I want to die

• Disregarded as a person

• Restricted opportunity

• Through / with my partner that has been racialized

• Excluded from places & activities or processes

• Loss of jobopportunities

• When helping clients receive services

• Stigma seen in mywork advocating forpeople with mentalhealth issues who are denied housing, clerical jobs, had their children taken away by CAS or incarcerated

• Perceptions

• Ignored

• Felt in danger

• Having an undergraddegree in recreation –no being takenseriously – not a“smart” degree

• Damaged self-esteem

• Missed opportunities

• Mechanic spoke to my husband about MY car repair – ignored me

• Felt ‘less than’ –children impacted inthe education system

• Equal pay for equal work

• Sexism in theworkplace

• Deteriorate friendships – judgment about accessing mental health services and being a worker

How have I been impacted by stigma?

(Participant responses)

STIGMA

AFFECTS

OUR

SOCIETY

AS A

WHOLE.

• As soon as you’re in recovery we can address your mental health

• As soon as your mental health is stabilized we can let you into treatment

STIGMA

+ concurrent disorders

STIGMA+ the recovery community

• Once an addict, always an addict

• They can’t take too much stress or they relapse

• Job loss and red lining in recovery

• If I tell anyone their opinion of me will go down

• I wasn’t a “low bottom” user

• Recovery isn’t for those that need, it’s for those that want it

• Your relapse helps keep me sober (recent newspaper article)

• Harm reduction isn’t treatment; itjust enables people to keep using

• Harm reduction supports addiction

• Harm reduction is for the poor –treatment is for the rich

STIGMA + harm reduction

• They are not clean of drugs

• You’re not really in recovery until you are drug free

• It’s active addiction disguised as medication

STIGMA

+ medically-assisted recovery

• Dirty

• Can’t handle life

• Lazy

STIGMA + drug use

• Well at least I never did that . . .

• I can’t believe people mess up on wine

• If that’s all I did I wouldn’t need treatment

STIGMA

By substance, method of use

• Can’t be trusted

• Doesn’t want recovery

• Unwilling

STIGMA + recurrence

• Painful injuries are seen as drug seeking

• Requirements for abstinence for treatment

• Lack of services

• Lack of funding for services

STIGMA

+ access to standard health care services

• Indigenous stereotypes

• Irish, therefore I drink

• Sikh, Muslim and other such communities where to drink or consume drugs is against religious principles

STIGMA+ cultural implications

STIGMA IS

REAL –

ESPECIALLY

WHEN IT'S NOT

INTENTIONAL.

THANK YOU

Andrew Berthelet

CAPSA Ottawa

aberthelet@capsa.ca

www.facebook.com/CAPSACanada

twitter.com/RDO_JRO

www.instagram.com/recoverydayottawa/

What can I do to reduce stigma?

• Put the person first

• Treatment is treatment –

harm reduction to

abstinence

• One humanity – treat people

as people

• Be kind

• Speak up

• Be gentle

• When you hear language that

is stigmatizing – say

something

• Person centered language &

client perspective lens

• Listen

• Educate self about

something I don’t know

• Educate on informed trauma

at entry level into the

organization

• Educated people. More

stories. Awareness. Calling

people out.

• Educate others on proper

language

• Education

• Hear, see, care

• Choosing better “words” and

being more mindful

• Valuing wellness and healing

• Consider language

• Take a look at current

policies within the agency

that structurally stigmatize

individuals – provoke change

• Review agency policies and

staff using appropriate

language

• Treat mental health and

addiction together

• Use myself as an example of

how stigma is demeaning

and hurtful, e.g. “I have a

mental illness; would you say

I’m crazy?”

• Put the person first

• Be mindful of language

• Educate and reframe

• Educated about mental

wellness and substance use

• Challenge my automatic or

unintended judgments of

others

• Language

• Keep speaking up and

challenging others

• Be gentle with yourself

• Be considerate to others

• Stigma ends with me

• Influence politicians

• Person first terminology

• Be aware of our language

• Practice & encourage self

compassion

• Speak out and speak up for

those without a voice or who

can’t do so – so their voice is

heard and we are one voice

• Be fair & be kind

• Educate family, friends, &

whoever else that might have

stigmatizing opinions

• Speak up - & point out that is

stigma

• Listen

What can I do to reduce stigma?

(Participant responses)