Meaningful engagement with people who use drugs - Emily Winkelstein, MSW Community Engagement Manager - National ...
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Meaningful engagement with
people who use drugs
Emily Winkelstein, MSW
Community Engagement Manager
Bureau of Alcohol and Drug Use Prevention, Care and TreatmentAnonymous survey exercise • Reactions? • Thoughts? • Were there any statements that you struggled with? • What was the point of this exercise?
Agenda • Context: Drug policy and stigma • Harm reduction • Stages of change and realistic goal setting • Effective engagement • Exercise
CONTEXT: DRUG POLICY AND STIGMA
Social determinants of health
Individual factors and
Neighborhood,
social/community
physical environment, Education
context (race, gender,
housing stability
immigration status)
Economic stability,
Food employment access, Health care access
job security
Health Outcomes
Mortality, morbidity, life expectancy, health care costs, health status
Adapted from Kaiser Family FoundationHistoric US approach to drugs: Criminal/moral model • Drug use is morally and legally wrong • Emphasis on bad people doing bad things • War on drugs = war on people who use drugs • Supply reduction • Arrest/punish • Just say no/abstinence as primary goal • Laws and enforcement applied inequitably • Insufficient reliance on expert knowledge and scientific evidence
Key factors shaping drug policy • Power, status and social control • Structural racism • Stigma • Economics • Privatization of prisons and jails • Pharmaceuticals • Gentrification • Business of enforcement • Media representation • Perception of risk
Stigma justifies this approach
• Stigma: A social process which can reinforce relations of
power and control and leads to status loss and
discrimination for the stigmatized
• Drug-related stigma has been largely normalized
• Significant stigma of related to substance use and
treatment for substance use
• Internalized
• From individuals
• Institutionalized
Link and PhelanAnd that’s the most harmful thing — even more than
the drug itself — it’s the emotional feeling that people
have about themselves, how they view themselves, how
they believe people view them. I think it’s the worst
harm ever — more than any drug that a person could
choose to do, it’s the emotional, internal feelings that
they have towards themselves, as a human being, as a
person.
- Louis Jones, person who uses drugs and activistPotential consequences for PWUD Potential for: • Increased risk behaviors • Decreased willingness to engage in care • Lower self esteem • Decreased willingness to disclose health information related to substance use • Decreased quality of relationships/social interaction • Chronic stress • Family and friends don’t seek support/help either
If you are suffering with an issue of addiction, stigma can
crush you. Stigma is what says your drug and alcohol use
is a character flaw. It’s what says you're a bad mother, it is
what says you are a bad son, or a bad husband. It is what
says you are weak, that you are crazy, that you are a piece
of crap. It is why you are afraid to tell your boss that you
need some time off to go get help. It is why you would
rather lie than tell someone that you are not doing okay. It
was why I would rather steal than let people know I
needed help.
- Brian Whitney, thefix.comPotential consequences for providers Potential for service providers to: • Prejudge patient motivation and engagement • Set unrealistic goals (i.e. set people up to “fail”) • Be less personally engaged • Lack empathy • Provide suboptimal care • Miss the mark (diagnoses or referral) • Feel unsuccessful, and possibly angry and/or resentful
HARM REDUCTION
Harm reduction as an alternative
• Harm reduction is an approach, not a single
intervention
• Emphasis on respectful, nonjudgmental, holistic,
person-centered help and support
• Sometimes people engage in behaviors that are
potentially harmful to themselves or others
• People may also be willing and able to make some changes to
decrease harm to self and others
• Acknowledges that individual goals may or may not
involve abstaining from substance use – and may
change over timeMaybe I don’t want you to be injecting
drugs, maybe I don’t want you to put your
life at risk. But that doesn’t mean that I
can’t accept that that’s what you’re doing
with compassion, and then see how I can
possibly be helpful to you.
- Dr. Andrew TatarskyThe words we use matter
More compassionate,
Potentially stigmatizing language
person-centered language
Addict Person who uses (or injects) drugs
Person living with a substance use
Substance abuser
disorder
Junkie / Dope fiend / Tecato(a) Person experiencing addiction
Substance abuse Substance use or possibly misuse
Currently abstaining; making
Clean
changes to drug use
Doctor shopper / Drug seeker Patient / Participant / Client
Replacement / substitution therapy Medications for addiction treatment
Would you consider? / Can you try
You should / shouldn’t
to avoid
Other loaded words: Relapse, recoverySTAGES OF CHANGE AND REALISTIC GOAL SETTING
Stages of
Pre-Contemplation
Change
Prochaska & DiClemente 1982
Lapse/Relapse Contemplation
Lapse/
Relapse
Maintenance Preparation
Lapse/ Lapse/
Relapse Relapse
Prolonged Action
MaintenanceMatching Strategy to Stage
Establish rapport, increase client’s perception of
Pre-contemplation
harms related to current behavior
Elicit reasons for change, explore ambivalence/risks of
Contemplation
not changing, elicit self-motivational statements
Offer a menu of options and strategies for change,
Preparation
draw on experience/knowledge
Action Support a realistic view of change through small steps
Help the client identify and use strategies to prevent
Maintenance
return to old behavior
Lapse/relapse/slip/use Explore the reality of lapse as a learning opportunityCycle of problematic engagement
ACTION
Client ODs, CM concerned for
safety; refers to detox “for own
good”
INTERNALIZED/ LIMITED OPPORTUNITIES
REINFORCED
Stage ignored; no risk reduction;
Feels like a failure; still doesn’t no naloxone; no connection to
understand risk/resources;
other services
ashamed to seek assistance
STEREOTYPES/ LABELS ACTION/REACTION
Couldn’t control himself; didn’t
Person leaves detox early; uses;
care about his family; only
overdoses again
wanted to get high; selfish; weakMEANINGFUL ENGAGEMENT
So what makes it meaningful engagement? • A trusting relationship • Willingness to disclose, ask questions, seek support • Process of mutual learning • Realistic goal setting • No one size fits all • Celebrating “any positive change” as success • Baby steps are big deals • Change doesn’t require action • Holistic • Honors personal experience, including impact of stigma
EXERCISE
Practice
• Divide into groups
• Discuss your scenario
• Identify:
• Stigmatizing language, actions or policies
• Possible suggestions to make language more
compassionate
• Potential indicators of stage and opportunities to
engage
• Potential successes/measures of successYou can also read
