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Notes on the Management of Spoiled Identity

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During my placement particular attention was given to stigma and labelling, as the majority of the residents were drug users, most of them been stigmatised countless times in their lives on different levels: public, private and institutional. At times, they were multi stigmatised as they were also homeless and some of them offenders. Attending a training session regarding substance use and stigmatisation helped me furthermore to reduce the effect of stigma on the residents and empower them in different ways.

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Stigma is a universal phenomenon and, at some point in our lives, all of us felt stigmatised. For instance, I have been labelled for my brown skin colour, for my Indian race and for being a woman.The ideas of stigma and stigmatisation are identified in Goffman’s Stigma. The issue occurs when a particular defining feature of a group’s identity becomes the so-called ‘master status’ . For instance, ‘ drug addict’ is a master status and this attribute can become the filter through which an individual’s other characteristics are seen.

Some rules have been set amongst the society which influences the day to day lives and activities of individuals within the society. This later leads to what may be termed as ‘ stigmatised or labelled’; that is when others refuse to follow the rules set by the society due to either their physical, mental or social conditions which are peculiar to themselves and as result, are being ignored or looked down upon by the society ( Stafford and Scott, 1986). Therefore, the characteristic is being a substance user in a society where drug use is illegal. 

According to Becker, this attitude as the social reaction arises from the so-called ‘deviant’ behaviour. His labelling theory explains two types of deviance i.e. primary and secondary. While the primary is the behaviour inconsistent with social norms such as mental health issues ( depression, anxiety ) and speech defeat, the secondary is the public reaction, for instance, a court order that restrains the person with addiction from working, limited trust from society and suspicious behaviour from the public. It is also distinguished two forms of stigma concerning substance use, which can be labelled as perceived devaluation and alienation . Lack of support and all the above factors contribute towards making people with substance use to consume more and more drugs.

Link and Phelan  add the importance of power relations to the description of stigma. The five interrelated components that concentrate to lead in stigma are labelling, stereotyping, separation of us and them, status loss and discrimination, and power differences. Regarding labelling, the majority of differences between people are ignored, only some, such as skin colour or gender carry social significance. Stereotyping happens when a label links a person to a set of undesirable characteristics, often in an unconscious way. Stereotyping of others as having bad characteristics eases the separation of us and them. They also point out how language helps the separation by saying a drug addict rather than a person addicted to drugs. Or also, handicapped rather than a person with impairment or disability. These terms are being utilised also in the literature which helps to spread. Thus, when people are labelled, stereotyped and set part, consequently they lose status and feel an individual and structural discrimination. In the end, by the creation of stigma, there is a power imbalance between the stigmatised and the stigmatisers. In order to stigmatise the other group,one group has to dominate and the stigmatised group has also the potential to resist the stigmatisation process. The efforts to change stigmatisation need to be multidimensional, along with the ability to change either deeply held stigmatising beliefs within powerful groups or the power imbalance between groups.

Literature shows that at the individual level stigmatisation can boost the self-esteem of the stigmatiser through a downgrading comparison of devalued groups. The stigmatisation provides a set of expectations about people such their likely behaviour, values and lifestyles. Stigmatisation revolves around a ‘ mark’ that denigrates an individual, therefore it is connected with stereotyping. On the other hand, prejudice is used to describe an antipathy towards an individual based on a stereotypical generalisation. The reactions of people to act with prejudice does not involve only negative thoughts, but also emotions such as anger, hostility and disgust. The person who is stigmatised is almost always the target of prejudice. At the end, discrimination is the unfair treatment experienced by the stigmatised for instance in seeking housing, employment etc.

In accordance with Aherm stigma and discrimination can have effect on the health of users. Rejection by others and expectations of rejection may cause chronic stress and can lead to coping, resulting in harming of mental wellbeing. Such consequences can fuel even more drug use,other addictions such as alcohol,leading to further isolation, and ultimately a vicious cycle that is hard to break out of.This sort of continuous stress can have impact on users physical health through neuroendocrine process. 

Furthermore,two areas where stigma can negatively impact are: Willingness to attend treatment and access to healthcare; harm reduction.

The pharmacy is one of the main public areas where a drug user’s world crashes with those of wider society. This is the place many drug users receive their methadone treatment, where their ‘master status’ can be made public. Drug treatment services can also form part in the process where their identities become reduced to their master status of a drug user. This can prevent them from seeking treatment. Hence,the treatment services need to maintain their focus on the whole person and not see the drug user as only drug users.

At times hospital professionals can be judgmental in dealing with a drug user. The users can perceive stigma in hospitals or General Practitioner’s office by non-verbal communication of the professionals such as their body language, look, attitude etc. This can be a reason which discourages them from accessing health care facilities. On the other side, having a trusted doctor or a key worker is associated with maintaining a good quality of life. In fact, a female resident stated to me that the few times she did seek care in a hospital, she experienced discrimination and received lesser quality care. In fact, in the fear of drug shaming, some of the other residents stated they hid their drug use in the hospitals when they were there for other health conditions. Therefore, as a barrier to care, stigma can adversely affect both mental and physical health by blocking entry to the health care system, reducing in this way accurate reports of health conditions, and lowering the quality of care received.Subconsciously they are led to lie about their drug use and do not get adequate treatments, in order to not have certain looks on them. 

Harm reduction refers to public health interventions such as needle exchange, clean sharps, distribution of naloxone kits and substitution therapies. These approaches are not usually supported by the public and believed by some as a facilitator of drug use, despite evidence showing that they decrease drug use’.

Some of the residents disclosed to me they felt rejected and others stated feeling anxiety in the presence of ‘ normal’ people. The general public perceives people with drug addiction to be dangerous,unpredictable and hard to talk with. These lead them to not have contact with no drug users. The families of substance users are also stigmatised, judged as partly responsible for their loved one’s addiction. One of the huge impacts is on the user’s sense of self-worth. An important part of the stigmatisation process is that the stigmatised person accepts the world view and ‘ be intimately alive to what others see as his failing’. It was evident during the placement of how discrimination has led many drug users to internalise and blame themselves for their situation. ‘This loss of confidence and self-esteem is a serious debilitating factor and a key obstacle to recovery.

For stigmatisation to take place, the stigmatised people must accept the social meaning of their stigma and feel the associated rejection, and the stigma must be central to people’s sense of self. Thus, for many residents, drug use becomes the central, defining feature of their lives, concerned in thinking about their drugs and how they will be able to get them.

The level of stigma perceived by substance users carries on even when the drug use is reduced or ended and remains strongly associated with mental health symptoms. The stigma continues to haunt the ex-users preventing access to good housing and employment. An example of increasing contact between public and drug users can be volunteering. Also, tackling dental problems can bring benefits in terms of social reintegration.

From my understanding, seeing drug use as a health matter rather than a crime can lead to less stigmatisation. Although alcohol, nicotine and caffeine are legal drugs and there are prescribed drugs for controlled use, the illegal status of heroin, cocaine and other drugs plays a vital part in the stigma attached to drug users.For instance, in countries where soft drugs are legal, such vision is not negatively perceived, as their policy is directed by an idea that every human being may decide about the matters of its own health.

Conforming to the World Health Organisation (WHO), stigma is a major cause of exclusion and it contributes to the misuse of human rights. Thus, during my practice period, I encouraged substance users to seek help and get on the journey of recovery, as it was necessary to reduce the stigma around their situation. I adopted a non-stigmatising behaviour which through I supported them in a non-judgmental and empathetic way. They do not easily trust or be open with anyone, so as a professional I created a safe setting where they could express themselves without feeling any weigh of judgments. 

It was clear that individual behaviour change is the primary focus at the intrapersonal level. Therefore, it was essential to provide interventions aimed at modifying characteristics of the person such as self-concept, improving self-esteem, coping skills, empowerment, and economic support.

It is said empowerment is the opposite of self-stigmatisation. My first step consisted in promoting their participation in formulating support plans using Smale et al’s exchange model and a person-centred approach. By doing this, I helped them to acquire some power in taking control of their lives. However, to take it forward it was necessary to create a relationship between myself and the residents. One of the skills I used the most was active listening as the majority of the time their stories or issues were unheard or ignored, therefore having a person to listen to them with no judgments made a huge difference for them. I could instil trust in them as I viewed them as human beings, not as people who use substances. I always displayed kindness and offered compassionate support, for instance by chatting to them, spending time with them during meal times or accompanying them to different visits or appointments, by giving the push in the right direction in their moments of hesitation.They never hesitated to come to me if they had any sort of issues, as I was always reliable.

Although initially, it was very challenging for me to initiate conversations with drug users, by undertaking research on different drugs and their dependency, reading journal articles and a variety of theories on what could be a potential reason behind their substance misuse, facilitated me to interact with them.I realised how difficult it was when I did not have enough knowledge around the topic to build a relationship and understand them adequately. Despite having worked in other fields, it was my first time dealing with substance users and I took it as an opportunity to broaden my knowledge and improve on a professional level. Therefore, anyone can easily jump to conclusions when there is no clear understanding of the matter. Hence, as a professional I believe everyone should have a solid base of knowledge skills and understanding to consequently deal with any type of service users, independently from their issue.

Few theories that informed my practice were the gateway theory of Dupont (80s), where it is said that misuse of one substance acts as a getaway, leading on to other, more fearful or potentially hazardous substances; Bandura’s  social learning theory, where an individual may learn that certain behaviours have particular outcomes from observing others; Opponent process theory, when a drug’s pleasurable effect will decrease by time and the withdrawal responses take over, to the point that the person is likely to continue to take drugs to avoid the withdrawal symptoms etc.

I also initiated cooking sessions on a weekly basis, where they could improve and learn cooking skills as well as socialise with other residents. The cooking activity was a successful attempt where though carrying out a daily and simple activity, I managed to gain their trust and understand them better.The group activity also helped to break the barriers between them and myself, as they felt more relaxed as it was an informal setting to get to know each other where they could open up about their life. Since they have a tendency to auto isolate, create a group environment, helped them and myself.

On an interpersonal level, the aim is at changing the affected person’s environment. These interventions deal with the impact of social support and social networks on health status and behaviours. Thus, establish relationships between members of the individual’s interpersonal environment in order to have the, share ways to promote their health. For instance, once the resident’s needs were assessed, I always informed them about the different support or services available, so they could make a choice. Since most of the drug users of my unit were suffering from mental health issues, I advised them about the mental health nurse coming to the unit on a weekly basis, if they wished to have a chat with her. I undertook different agency visits such as in Cairn Centre, Addaction, Jericho House, Integrated Substance Misuse Service and Tayside Council on Alcohol, so I would know how to best support the residents with their substance use. I also encouraged different residents to go to the General Practitioner or the hospital when they had an abscess on their body as a consequence of injecting illegal drugs, offering to accompany them.

Stigma reduction strategies at the community level aim to increase knowledge regarding specific health conditions and regarding stigma within specific community groups. At the starting of placement, I was proactive and undertook training on substance misuse and stigmatisation and I found it very helpful. I also undertook naloxone training to manage opioid overdoses as several people in the unit overdose on a monthly basis. More trainings which can potentially inform practice should be conducted for students and professionals, so they could remove some barriers or attitudes they self create in their head. 

These interventions also intend to increase community development skills, to develop support networks, and through these provide better access to services for people affected. 

Stigma consists of three related problems: the problem of knowledge such as ignorance, the problem of attitude such as prejudice, and at the last, the problem of behaviour, which is discrimination. I strongly believe education is often the first step in stigma reduction and is often combined with other interventions. It involves strategies that focus to inform the general public and community groups by increasing their knowledge about a specific condition and by correcting misinformation and negative attitudes and beliefs. For instance, the drug education in the schools should include stronger attention to the nature, causes and consequences of addiction. Users and their families may also benefit from a better understanding of the nature of addiction, which consequently can help to reduce the self-blame felt by some user’s families.

The media have a huge role in putting wrong information in people’s heads, therefore, the use of negative language in it could be challenged and could potentially stop the use of the word ‘junkie’. Also, the terms ‘abuse’ and ‘misuse’ are increasingly being disputed.      

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