Riff raff not welcome – the poison of professional stigma

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StigmaWhy do some health care professionals turn their noses up at the prospect of treating alcoholics or addicts? GPs can opt out of offering evidence-based opiate replacement therapy (ORT) to opiate dependent patients. They don’t opt out of treating hypertension or diabetes. And this is by no means a primary care issue. Generic mental health services are not always welcoming to those with substance dependence.

Some professionals will say they that don’t have the skills to do this, but the skills have been gained by those with the will to learn and do the best for their patients. Take a look at the work of the Royal College of GPs or SMMGP for evidence.

Despite good practice problems persist. Could it be that professional stigma against those suffering from addictions is at the heart of some of this? If so, such attitudes are likely to be poisonous to recovery.

Bill White tackles the subject of professional stigma on his blog. He points out two ‘stark historical realities’:

One, there would have been no reason for a specialized field of addiction treatment if these systems of care effectively addressed the needs of people with severe alcohol and other drug (AOD) problems. Addiction treatment was built on the failure of these allied systems to address such problems.

Two, people with severe AOD problems have been historically excluded, mistreated, and forcibly extruded from mainstream systems of care.  The implicit message was: “Riff raff not welcome.”

White argues that the transition from historical ‘moral depravity’ to ‘legitimate patient’ is not an easy one to make. He says that despite those with addictions being a ‘billable commodity’, that this:

has not changed the underlying atmosphere of disrespect and contempt which people with severe AOD problems all too often continue to face.

The root of the problem, argues White, is that while caregivers are constantly exposed to the problematic behaviours associated with addiction, they don’t routinely get to see people in long-term recovery on a regular basis. The result is clear:

Within their professional roles, they know the problem intimately but rarely witness the lived solution.

So what is the answer to the dilemma?

Recovery-focused training of allied professionals is essential to altering these conditions, but people in recovery also have a role to play in this process.  Nothing is more effective in altering social/professional stigma than contact strategies, e.g., personal encounters with people in long-term addiction recovery.

Bill White closes his blog by quoting from a speech he made to a Recovery Summit in Minnesota in 2001.

“There are whole professions whose members share an extremely pessimistic view of recovery because they repeatedly see only those who fail to recover.  The success stories are not visible in their daily professional lives.

We need to re-introduce ourselves to the police who arrested us, the attorneys who prosecuted and defended us, the judges who sentenced us, the probation officers who monitored us, the physicians and nurses who cared for us, the teachers and social workers who cared for the problems of our children, and the job supervisors who threatened to fire us.

We need to find a way to express our gratitude at their efforts to help us, no matter how ill-timed, ill-informed, and inept such interventions may have been.

We need to find a way to tell all of them that today, we are sane and sober and have taken responsibility for our own lives.  We need to tell them to be hopeful, that RECOVERY LIVES!”

Every time someone in recovery goes back to their GP, their CPN or their psychiatrist and tells them what has worked, they will make a difference. Every time a peer supporter volunteers to help other in the treatment system, they will make a difference, not just to the service users they are helping, but to the professionals in the system.

But there’s more. The recent recovery walk in Manchester has been reported as attracting 8000 people. In a week, Scots in recovery and their supporters will walk the Royal Mile in Edinburgh. As Kuladharini (CEO of the Scottish Recovery Consortium) details, community recovery resources are springing up everywhere on an unprecedented scale at phenomenal rates:

In 2012 there were only 11 of these visible, independent recovery support groups in Scotland; in June 2014 we counted 72; led by people in recovery and friends of recovery for people in recovery and the communities they inhabit. In 2012, the chances of them knowing each other were slight. Now the 72 are building into a conscious national network as they lead the planning for this year’s Recovery Walk Scotland.

Such large demonstrations give a positive face and a voice to recovery. They show that recovering people are not ‘riff raff’, but valuable community assets. Over time the visible evidence of recovery in action will provide an antidote to the poison of professional stigma.



    9 Responses to "Riff raff not welcome – the poison of professional stigma"
    1. Adam says:

      Those professionals that do engage, but do so from a harm reduction rather than recovery perspective, treat addicts like victims / children. They seldom respect them as true equals.

      • Innocent Abroad says:

        Adam, who do we respect as “true equals”? All other human beings; or only those whose cultural behaviour you feel comfortable with (i.e. does not evoke a “fear of difference”); or only those who have passed some kind of test in your mind so that they deserve to be treated equally? The answer is not as straightforward as either of us might like it to be.

        The reframe from moral denunciation to medicalization of AOD abuse is a consequence of prosperity. Older professionals, or those who have immigrated here from less prosperous cultures, may find the reframe offensive.

      • Detox Nurse says:

        I think you, as have others, have conflated a harm reduction treatment modality with a treatment for addiction. The harm reduction approach is not a treatment for addiction in the same way as say mutual aid is. You do not have to be dependent on a substance to benefit from a HR message.

        In his book The Chemical Carousel, Dirk Hanson suggests that only around 1/3 of people who use heroin will become dependent on the drug. Add to this the millions of people who casually use other substances unproblematically without ever tipping into addiction. Were as I’d question the use of a ‘recovery’ approach for this population, a harm reduction approach (“when you use heroin, you might want to avoid mixing it with alcohol”) is far more befitting.

        The treatment of addiction does not have a monopoly on the ‘treatment’ of all substance use and therefore a range of interventions are required from across the spectrum of harm reduction and recovery.

        Ultimately, your comment is symptomatic of the current black and white thinking that seeks to throw the baby out with the bathwater.

    2. djmac says:

      I think the problem is not just limited to harm reductionists – ‘professional knows best’ is an attitude encountered not infrequently across the caring professions. Some of my colleagues working in harm reduction have incredibly positive attitudes to recovery and focus them on empowerment for the client.

      There can be a tension I think though between promoting public health interventions like harm reduction and empowering the person to look after their own recovery and achieve personal goals.

      There are two contrasting articles in this week’s British Medical Journal – one by Dr Margaret McCartney arguing for large scale public health initiatives like plain packaging for cigarettes and reduction in sugar in foods and the other by Jo Bibby arguing for people to take personal responsibility for their health.

      My conclusion is that we need both public health and personalised approaches but I acknowledge there will be tensions at the interface.

      I agree with the principle underlying the point I believe you make. Namely that where professionals treat clients/patients like children they end up disempowering them.

    3. Detox Nurse says:

      I recall a telephone call from a women from mental health services. She wanted to refer a patient to our service, but wondered if he could be seen elsewhere as he didn’t want to mix with our client group and, she went on to explain, nor would she if she was in his position. I nearly put the phone down.

    4. Anon says:

      This is perhaps a side issue but I always imagined that if any group of professionals did see people in recovery it was GPs – whereas in practitioners in. specialist services typically lose contact with clients as they move into sustained recovery, GPs remain in touch with them through the years.

      Similarly, and perhaps naively, I always think that they will understand the needs of the families of those in active addiction better than other professionals simply because they will often be the only people in touch with them.

    5. Chris Ford says:

      Dear djmac Really important blog, thank you.

      I feel stigma is the biggest hurdle that people who use drugs, and at every stage of their journey, face. Some of my colleagues (doctors) are the worst offenders, although many others are wonderful and embrace all elements of this work. I have often thought of taking a doctor to the GMC for not caring for people who use drugs because as you say if it was someone who had diabetes or blood pressure they would not only do it but would be in trouble if they didn’t!

      What I can’t understand is I have always found people who use drugs the most interesting, willing to work, kind, helpful and wonderful people to work with and learnt lots about myself! Only comment I disagree with is with Adam’s comment – please lets stop the division between harm reduction and recovery – it isn’t helpful and for me it is all part of the same spectrum. It is a spectrum and have patients on medication who are well into recovery and others who are abstinent who aren’t. Recovery is a self-defined journey, which consists sometimes forward and sometimes back but always positive change – I have been on it for 63 years and still got a long way to go!

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