In the first of a series of shorts hosted by national charity Scottish Families Affected by Alcohol and Drugs (SFAD), attendees heard that stigma around with alcohol and drug use worsens people’s mental and physical health.

Drawing from personal and professional perspectives, the Head of Policy, Practice and Communication at membership charity Scottish Drug Forum shared that stigma permeates across attitudes, relationships and services – influencing how people access or engage with support.

As part of the series aiming to reach people across the third sector and those affected by decisions, policy and attitudes around alcohol and drug use, Austin Smith urged attendees to consider the consequences of stigma.

As the Head of Policy, Practice and Communication at the Scottish Drugs Forum (SDF) working to improve Scotland’s approach to drug-related issues, he said that while there has been some “remarkable progress”, better conversations are needed around drug and alcohol use stigma.

Bringing together his experience around alcohol and drug use, Mr Smith said:

“My first lesson is stigma ruins lives and kills people. Stigma is a serious issue.

“Although this isn’t in people’s job descriptions or at the front of their minds, stigma is a hugely important issue – as are its consequences.

“People can be regarded as problematic in terms of the general public and those with influence. People with a drug or alcohol problem are regarded as ‘damaged’ or ‘damaging’ individuals.

“You see this around when people are identified as criminals, almost by definition because drug possession is a criminal activity under UK law – you’re defined by your criminality. If you’re involved in criminal activity to pay for your drugs or alcohol, you’re regarded as a criminal and therefore an untrustworthy character.”

While the Scottish government has advocated for decriminalisation of all drugs for personal supply as part of its wider efforts to reduce drug-related deaths, legislative changes would need to be introduced by Westminster.

Mr Smith added that tackling stigma and supporting recovery requires change at all levels, starting by challenging harmful attitudes and stigmatised language.

A “painful identity that’s been made for them”

Mr Smith said stigma is not isolated to one part of an experience but rather the variety of behaviours or identities a person may struggle with when facing addiction.

This spans from potentially criminal activities to relationships with family or even the healthcare system:

“One obvious one is that criminal thing, another one is the moral thing of you’re untrustworthy or you’ve stolen.

“And another, is the medicalised stigma that you ‘have a disease’ – addiction or substance use disorder – and that also potentially you ‘carry disease’, particularly for those who engage in injection drug use.

“There’s also the wider judgement of what might be regarded as ‘abnormal behaviour’. You’re doing something that other people don’t understand or can’t rationalise, so you must have a mental health problem, or have taken on a completely different set of values from the rest of society. You’re a ‘dropout’, you’re somebody on the ‘edge of society’.

“The idea that you lack self-control, you’re weak or you’re self-indulgent or irrational, or you might be identified as someone to be feared because you might be violent or abusive. This then leads to the judgement of whether you deserve help – you’re unworthy or you’re undeserving.

“A phrase that’s used often is ‘hopeless’, you don’t have hope for yourself, and other people don’t have hope for you.”

Mr Smith said people can often face stigma multiple times a day, and all of those perceptions and judgments can become internalised; a part of how people see themselves.

This, he explained, contributes to poorer psychological wellbeing, diminished self-esteem and often leads to further harmful drug and alcohol use.

Isolation and a lack of engagement with services can then follow, he said:

“People want to hide from those painful feelings and that painful identity that’s been made for them. You really see this in people’s engagement with services – people engage with treatment and support services really late on.

“People maybe ask for help, don’t get a good reception and then go away for years and years never asking for help and then come back.

“That late presentation leads to physical and mental health problems and all kinds of terrible consequences, often with people presenting in an emergency setting.”

He added that under-resourced and understaffed health services compound the impact of stigma on access to health services, with 10-minute GP appointments not lending themselves to a person-centred approach.

Missed healthcare appointments are often rooted in the interactions between people and healthcare systems, with patient expectations and bad prior experiences all playing a role, according to new research.

Professor Andrea Williamson a deep-end GP and Professor of General Practice and Inclusion Health, told healthandcare.scot that siloes and exclusions in health services drive a sense of ‘this is not for me’ among patients.

She said reframing of the narrative when it comes to addiction and recovery services is needed, echoing Mr Smith in highlighting the detrimental impact of stigma:

“Important action is being taken already – led by people who are themselves in recovery from substance use, showing by example that recovery is possible and something to aim for.

“However, it’s vital also that society and our communities change the narrative about what drives drug related harms – its overwhelmingly related to the experience of adversity over a person's life, not that the person is ‘deviant’ or ‘bad’.”

Current state of policy

Professor Williamson added that beyond a narrative shift, more attention and resources are needed across policy areas:

“Supporting children, young people and adults to overcome that adversity needs much more policy attention and resources: well-funded schools, quality housing, a benefits system that is a support not a punishment, investment in local communities and low threshold high quality mental health care. It all matters and we are failing so many people at the moment.”

Reflecting on Scotland’s drug and alcohol crisis, SDF’s Mr Smith says Scotland’s work on stigma appears to have been “very slow in progressing, almost as if there’s no change”.

However, he said individuals working on the ground tell a different story:

“When you come out and speak to people working with these issues every day, there is quite substantial cultural change in Scotland which is changing, if not eliminating, stigma around drug and alcohol use.”

Yet, he added that work must continue – on an individual, organisational and national level.

He explained that people can inadvertently reinforce stigma in attempts to empower people or challenge stigma around recovery from alcohol and drug use.

He said the complicated nature of creating stigma within public policy – from smoking in public places to seatbelts in cars – means that nuance is needed when approaching alcohol and drug policy:

“Language matters and attitude is key. When you see stigmatising attitude, it leads very quickly to stigmatising behaviour.

“This may occur with staff and services in specialist treatment or support, or just mainstream services as well as everyday life. A lot comes from fear or ignorance so think about: what’s this person scared of – and what could they learn that might change their attitude?”

Read more: Alcohol minimum unit price increase to 65p; Why people are left behind; Plea to hear the voices of drug death families; Experts: Drugs deaths need emergency response now; Recovery employment scheme grows; Safe consumption rooms key for drug harms; Ambulance plea: TRUST us in youth drug emergencies

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