Stigma and Service Integration
One of the emerging trends of U.S. health care reform is the tri-directional integration of addiction treatment, mental health services, and primary health care. This is evident in the growing integration of addiction and psychiatric treatment under the rubric of “behavioral health care,” efforts to integrate primary health care within addiction treatment settings, and increased delivery of addiction-related services within primary health care settings, e.g., physician offices, health clinics, and hospitals. Considerable resources have been invested in creating policy frameworks for such integration (e.g., provisions for office-based treatment of opioid dependence) and developing technological innovations (e.g., screening, assessment, and treatment protocol) to facilitate such integration, but history would suggest a far greater obstacle to service integration: social and professional stigma.
Efforts to integrate addiction treatment into mental health, primary care, and other service settings fail to address 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.” Today, we are trying to define as legitimate “patients” people who for more than a century were defined as unworthy of care based on their perceived moral depravity. The transformation of addicted people into a desirable “billable commodity” has not changed the underlying atmosphere of disrespect and contempt which people with severe AOD problems all too often continue to face.
Policy and technological advancements in service integration will proceed only to the extent that these perceptual and attitudinal barriers to effective care are eliminated. The stigma toward people with AOD problems long embedded within traditional systems of care is rooted in the fact that caregivers within these systems daily confront the consequences of acute and chronic addiction but have historically been denied exposure to people in long-term addiction recovery. Within their professional roles, they know the problem intimately but rarely witness the lived solution.
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. Below is the vision of such contact as an advocacy strategy that I presented in my closing remarks at the 2001 Recovery Summit in St. Paul, Minnesota.
“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! Americans see the devastating consequences of addiction every day; it is time they witnessed close up the regenerative power of recovery.”
This month, more than one hundred thousand recovering people and their families and allies will participate in public recovery celebration events in cities throughout the U.S. These events are part of a larger strategy to fundamentally alter how Americans view AOD problems and their resolution, but these large events may not be as powerful as an army of persons in recovery selectively disclosing in diverse interpersonal and professional encounters their status as a “person in long-term addiction recovery.” Professionals of all stripes can play a role in helping create the social and professional space within local communities in which such stories can be told.