What does stigma mean to me?
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
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
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)