Three Strikes and You're Out!

3 Strikes and You're Out!

Written by and for people with Lived Experience - Port Alberni Community Action Team - Families Helping Families

Today’s Learning Moment – 04 26 21 Issue: Three Strikes and You’re out! - Triple Stigmatization — Substance Use, Mental Health, and Criminalization

The stigmatization of people living with substance use challenges is destructive, pervasive, and unfortunately, all too common in health care settings across what we now call “Canada”. People who use drugs (PWUD) report stigma and discrimination as major barriers to seeking treatment, receiving quality care, and achieving recovery. This not only perpetuates health, economic and social inequities among PWUD but also isolates them from their families, friends and the larger community, thus eliminating many of their natural sources of support.¹

What is Stigma?
In making sense of stigma, it is important to note that it is not always tied to a person’s actual attributes or behaviour but instead related to making assumptions about their attributes or behaviours. Discrimination is the expression of these beliefs, resulting in the unfair treatment of people living with MHSU problems. Stigma and discrimination can manifest themselves in subtle ways (such as in the words that healthcare providers use to describe the person or the illness), or in more obvious ways (such as through institutionalized systems, policies, and practices).

The Stigma Attached to Substance Use
Compared to other health conditions, the stigma attached to having a substance use disorder is more complicated, as it is linked to a societal belief that people with substance use disorders have control over their health condition and are to blame for their behaviours.² A World Health Organization (WHO) study of the 18 most stigmatized conditions (e.g., being homeless, HIV positive, having a criminal record) in 14 countries found that drug addiction was ranked as the most stigmatized, and alcohol addiction was ranked fourth.³

Compounded Stigma of Substance Use, Mental Health and Criminalization
Substances are often used as self-medication for a mental health disorder, which to this day, is perceived as a moral failing and continues to be criminalized by the state. Unfortunately, many PWUD people experience the compounded stigma of having a substance use disorder, mental health disorder, and further, being criminalized for them. This triple stigmatization is intertwined and worsened by one another.

Many of the negative consequences of mental health stigma overlap with substance use stigma. People with mental health and substance use (MHSU) challenges are less likely to seek health care when they need it because they anticipate negative experiences based on past treatment ^{4 5}. When they do seek health care, they often receive poor quality care not only for their MHSU disorder but for their physical health issues as well. For example, “diagnostic overshadowing” – the assumption that a patient’s physical health complaint is not legitimate due to their mental health disorder ⁶ – is what was seen in the horrifying case that led to a man crawling out of a Toronto hospital: the patient experienced excruciating pain in his legs, but was dismissed once he disclosed that he was taking medication for bipolar affective disorder.

As seen in this case, and too many cases like it, the consequences of stigma in health care settings are dire, ranging from delay in necessary treatment to death ⁷.

Those who discriminate against PWUD also endorse more severe penalties for substance use.⁸ People who are criminalized struggle with accessing community-based health services, where they are perceived as “misfits” and “non-compliant. Criminal justice involvement also hinders employment prospects ^{9 10} which can, in turn, lead to more criminal behaviour to survive.¹¹ This is one of the reasons why many people are forced into a lifetime cycle of custody, probation violations, and repeat offences. Ironically, stigma leads to criminalization, which can lead to more criminal behaviour. Much of this is heavily targeted at people who inject drugs, who are more likely to be perceived as violent and dangerous.¹²

What We Can Do
As we all know too well, compounded on top of the triple stigmatization of mental health substance use, and criminalization is additional stigma related to poverty, homelessness, being Black, Indigenous, People of Colour (BIPOC), sex work, and the many more intersectional identities that humans have.

We can all do more to reduce stigma and create caring communities. Here are some places to start:

1.    Take the online Understanding Stigma course delivered by the Centre for Addiction and Mental Health, and share it with the people in your life. It is designed for healthcare professionals but is valuable to anyone.

2.    Use people-first language – for example, say “person who uses drugs” instead of “drug user”. For more information, visit and share this resource on respectful language in relation to sexual health, substance use, STBBIs and intersecting sources of stigma by the Canadian Public Health Association.

3.    Engage people with lived and living experience in all decisions that impact them. Read and share this framework on patient and family engagement by BC Mental Health and Substance Use Services to learn more about what meaningful engagement in MHSU care looks like, why, and how to do it.

All our past articles can be found here: https://ptalbcat.blogspot.com/
The link to this specific article is: https://ptalbcat.blogspot.com/2021/04/three-strikes-and-youre-out.html  SHARING is best done by copying and pasting this link everywhere you want.

Author: Katie Mai – Katie is a first-generation settler on unceded Coast Salish territories with ancestral roots in Guangzhou, China. She is the Leader of Patient Experience and Community Engagement at BC Mental Health and Substance Use Services, which delivers care to adults with concurrent disorders, people in custody, and people referred to treatment by the court.

Families Helping Families is an initiative of the Port Alberni Community Action Team. We send out “Learning Moment” articles regularly to help folks understand substance illness. Knowledge is vital in understanding the illness of our family members. You may copy, distribute or share our articles as long as you retain the attribution. You can be added to our distribution list by dropping us a note at - albernihelp@gmail.com

This article was written using info from the following sources:

References

¹ Corrigan, P.W. (2004). How stigma interferes with mental health care. American Psychologist, 59(7), 614–625.

² Yang, L., Wong, L., Grivel, M.M., & Hasin, D.S. (2017). Stigma and substance use disorders: An international phenomenon. Current Opinion in Psychiatry, 30(5), 378-388.

3 Room, R., Rehm, J., Trotter, R.T., Paglia, A., & Ustun, T. B. (2001). Cross-cultural views on stigma, valuation, parity and societal values towards disability. In T. B. Ustun, S. Chatterji, J. E. Bickenbach, R. T. Trotter II, R. Room, J. Rehm & S. Saxena (Eds.), Disability and culture: Universalism and diversity (pp. 247–291). Seattle, WA: Hogrefe & Huber.

4 Hanisch, S. E., Twomey, C. D., Szeto, A. C., Birner, U. W., Nowak, D., & Sabariego, C. (2016). The effectiveness of interventions targeting the stigma of mental illness at the workplace: a systematic review. BMC psychiatry, 16(1), 1-11.

5 Hanisch et al., 2016.

6 Henderson, C., Noblett, J., Parke, H., Clement, S., Caffrey, A., Gale-Grant, O., & Thornicroft, G. (2014). Mental health-related stigma in health care and mental health-care settings. The Lancet Psychiatry, 1(6), 467-482.
7 van Nieuwenhuizen A, Henderson C, Kassam A, et al. Emergency Department staff views and experiences on diagnostic overshadowing related to people with mental illness. Epidemiol Psychiatr Sci 2013; 22: 255–62.

8 West, M.L., Yanos, P., & Mulay, A. (2014). Triple stigma of forensic psychiatric patients: Mental illness, race, and criminal history. International Journal of Forensic Mental Health, 13, 75-90.

9 John Howard Society of Ontario (2016). Reintegration in Ontario: Practices, Priorities, and Effective Models. Retrieved April 20, 2021 from: https://johnhoward.on.ca/wp-content/uploads/2016/11/Reintegration-in-Ontario-Final.pdf

1⁰ Decker, S., Ortiz, N., Spohn, C., & Hedberg, E. (2015). Criminal stigma, race, and ethnicity: The consequences of imprisonment for employment. Journal of Criminal Justice, 43 (2), 108-121.

1¹ John Howard Society of Ontario (2016).

1² Brener, L., Cama, E., Hull, P., & Treloar, C. (2017). Evaluation of an online injecting drug use stigma intervention targeted at health providers in New South Wales, Australia. Health Psychology Open, 4(1), 1-6.

 

Additional References

·         Brener, L., Cama, E., Hull, P., & Treloar, C. (2017). Evaluation of an online injecting drug use stigma intervention targeted at health providers in New South Wales, Australia. Health Psychology Open, 4(1), 1-6.

·         Corrigan, P.W. (2004). How stigma interferes with mental health care. American Psychologist, 59(7), 614–625.

·         Decker, S., Ortiz, N., Spohn, C., & Hedberg, E. (2015). Criminal stigma, race, and ethnicity: The consequences of imprisonment for employment. Journal of Criminal Justice, 43 (2), 108-121.

·         John Howard Society of Ontario (2016). Reintegration in Ontario: Practices, Priorities, and Effective Models. Retrieved April 20, 2021 from: https://johnhoward.on.ca/wp-content/uploads/2016/11/Reintegration-in-Ontario-Final.pdf

·         Hanisch, S. E., Twomey, C. D., Szeto, A. C., Birner, U. W., Nowak, D., & Sabariego, C. (2016). The effectiveness of interventions targeting the stigma of mental illness at the workplace: a systematic review. BMC psychiatry, 16(1), 1-11.

·         Henderson, C., Noblett, J., Parke, H., Clement, S., Caffrey, A., Gale-Grant, O., & Thornicroft, G. (2014). Mental health-related stigma in health care and mental health-care settings. The Lancet Psychiatry, 1(6), 467-482.

·         Room, R., Rehm, J., Trotter, R.T., Paglia, A., & Ustun, T. B. (2001). Cross-cultural views on stigma, valuation, parity and societal values towards disability. In T. B. Ustun, S. Chatterji, J. E. Bickenbach, R. T. Trotter II, R.

·         Room, J. Rehm & S. Saxena (Eds.), Disability and culture: Universalism and diversity (pp. 247–291). Seattle, WA: Hogrefe & Huber.

·         van Nieuwenhuizen A, Henderson C, Kassam A, et al. Emergency Department staff views and experiences on diagnostic overshadowing related to people with mental illness. Epidemiol Psychiatr Sci 2013; 22: 255–62.

·         West, M.L., Yanos, P., & Mulay, A. (2014). Triple stigma of forensic psychiatric patients: Mental illness, race, and criminal history. International Journal of Forensic Mental Health, 13, 75-90.

·         Yang, L., Wong, L., Grivel, M.M., & Hasin, D.S. (2017). Stigma and substance use disorders: An international phenomenon. Current Opinion in Psychiatry, 30(5), 378-388.