UNDERSTANDING AND INTERVENING ON ADDICTION STIGMA LISBON ADDICTIONS

UNDERSTANDING AND INTERVENING ON ADDICTION STIGMA LISBON ADDICTIONS 2017 Karsten Lunze 24 Oct 2017

2 11/24/20 20 GOALS 1. What is stigma and where does it originate? 2. What is stigma’s impact on prevention? 3. How can we intervene on stigma?

3 11/24/20 20 GOALS 1. What is stigma and where does it originate? 2. What is stigma’s impact on prevention? 3. How can we intervene on stigma?

4 11/24/20 20 WHAT IS STIGMA? • Dehumanization of individual in undesirable social category • External, public stigma – Attitudes and reactions towards socially excluded groups – From providers, law enforcement officers, families, communities – Laws, regulations, cultural context represents structural stigma • Internal, “felt”, self-stigma – Experience of discrediting attributes result in devaluation, shame, stigma avoidance, fear of enacted stigma – Rejection further increases marginalization Goffman E. Stigma: Notes on the Management of a Spoiled Identity. Simon & Schuster, New York 1963. Kulesza Met al. Substance Use Related Stigma. J Addict Behav Ther Rehabil 2013 Luoma JB. Substance Use Stigma as a Barrier to Treatment and Recovery. Addiction Medicine, Springer 2010. Corrigan PW, Rao D. On the self-stigma of mental illness. Can J Psychiatry 2012 Ahern J et al. Stigma, discrimination and the health of illicit drug users. Drug Alcohol Depend 2007

5 11/24/20 20 WHAT IS DISCRIMINATION? Discrimination consists of actions or omissions that are derived from stigma and directed towards those individuals who are stigmatized. • Result of the process of stigmatization, when stigma is acted upon (“enacted stigma”) • Different and unfair, prejudicial treatment (to their disadvantage) Goffman E. Stigma: Notes on the Management of a Spoiled Identity. Simon & Schuster, New York 1963.

6 11/24/20 20 STIGMA MANIFESTATIONS • Overt or external deformations – Scars, physical manifestations, manifestations of physical disability or social disability • Deviations in personal traits – Mental illness, substance use disorder, unhealthy alcohol use, criminal background • "Tribal stigmas“ – Traits (imagined or real) of ethnic group, nationality, or of religion deemed to be a deviation from the prevailing Goffman, E. (1963). "Stigma: Notes on the Management of a Spoiled Identity. " Simon & Schuster, New York.

7 11/24/20 20 STIGMA MANIFESTATIONS • Anticipated stigma – anticipation of being devalued by others if the identity became known • Centrality – level of defining oneself by the stigmatized identity • Salience – frequency of thinking about the identity • Internalized stigma – the extent of agreement with negative stereotypes about the identity • Outness – extent to which other people currently know about the identity Quinn, D. M. , M. K. Williams, et al. (2014). PLo. S One

8 11/24/20 20 Operationalizing stigma General population, healthcare workers, affected people • • • Fear: of contact, infection, etc. Social judgment: shame, endorsement thereof Legal and policy environment: existence, compliance, awareness Anticipated stigma: hesitance to test, avoidance of services Internalized stigma: shame, blame, guilt Perceived stigma: talk, hear talk Stigma experiences: contact, avoidance, exclusion Discrimination: opinion about discrimination, preferences, denial Resilience: confronting, challenging, educating

9 STIGMA IDENTITIES OF PEOPLE WITH SUBSTANCE USE • • Mental illness Infections (HIV and others) Race Gender Experience of domestic violence, sexual assault, childhood abuse Identity as sexual minority History of criminal justice involvement … Goffman, E. (1963). "Stigma: Notes on the Management of a Spoiled Identity. " Simon & Schuster, New York. 11/24/20 20

Conceptualizing stigma Barrier to Health Care External stigma PWUD Social exclusion Reinforcing Factors Marginalization in society, discrimination, legal status, political factors Vulnerability, shame, guilt, trauma, criminalization with other stigmatized challenges HIV, HCV, homeless, sexual orientation, criminal justice involvem. Stigma determinants Resilience, agency, coping strategies, other mitigating factors Stigma therapy Health and Wellbeing Quality of life Mental health and wellbeing Protective Factors Other Stigma Identities Stigma education Interventions Access to health care Adverse effects on Health care utilization Social Integration

11 11/24/20 20 INTERVENTIONS • Public education • Advocacy • Provider training • Peer support • Personal empowerment

12 11/24/20 20 CONCLUSIONS • Solid body of evidence on various forms of stigma and health • Knowledge gaps regarding substance use stigma • Budding research field on intersectional stigma affecting PWID • Interventions to address public and structural stigma urgently needed • Interventions to empower affected people cope with stigma urgently needed