Health and social interventions in the context of support and control: The experiences of marginalised people who use drugs in Australia

Abstract

People who use illicit drugs frequently become targets for welfare intervention, often positioned both as complicit in the reproduction of intergenerational poverty and marginalisation, and as sources of hope for interrupting such patterns. This article draws on empirical research exploring the experiences of highly marginalised people with histories of illicit drug‐use to investigate how they negotiate service encounters in the context of the participants’ previous experiences with welfare interventions. In doing so, the article seeks to texture the conception of the support and control nexus, drawing out the systemic and service level factors of welfare services which inhibit people who use drugs from benefitting from available support. We conducted 12 in‐depth interviews with participants subject to interventions by health, social or legal services between July and September 2018. All interviews were audio‐recorded, transcribed verbatim and coded in NVivo. Transcripts were analysed using a grounded theory approach where data were subject to an iterative process of constant comparisons to identify emergent themes and theoretical concepts. The findings suggest that the blending of welfare services and systems of control has unintended and often negative consequences for highly marginalised people. In effect, the drug treatment programme's aims of assisting people to reduce harm and increase stability are significantly undermined by control mechanisms such as mandatory reporting policies. A better understanding of the ways in which welfare service processes alienate marginalised people from seeking support, as well as from benefitting from the support available, might provide a way to address these concerns.

Examining Relational Dimensions of Service Encounters for Disadvantaged People Who Use Drugs

“…For instance, good provider–consumer relationships have been identified as significant predictors of a lower risk of relapse into drug use because of physicians' whole-person knowledge of the consumer and consumer trust in their healthcare provider (Kim et al, 2007). However, disadvantaged people, including people who use drugs, bring unique relational histories to engagement with social and health services (Moensted & Day, 2020). Many come with a relational legacy of disappointment and mistrust of helping professionals (Treloar et al, 2016).…”

Staying safe, feeling welcome, being seen: How spatio‐temporal configurations affect relations of care at an inclusive health and wellness centre

“…Punitive ramifications for missing scheduled appointments (e.g., exclusion from services) are a widely accepted practice 4 . Working punitively fails to recognise homeless people's agency, 25 undermines health seeking, impacts therapeutic relationships and further entrenches marginalisation when greater levels of support are needed 26 . Wen et al 27 found that perceptions of being unwelcome affected the disposition to seek health care; while welcoming, friendly environments with flexible appointment structures have been shown to improve access to primary health care for socially disadvantaged populations 28 .…”

“… 4 Working punitively fails to recognise homeless people's agency, 25 undermines health seeking, impacts therapeutic relationships and further entrenches marginalisation when greater levels of support are needed. 26 Wen et al 27 found that perceptions of being unwelcome affected the disposition to seek health care; while welcoming, friendly environments with flexible appointment structures have been shown to improve access to primary health care for socially disadvantaged populations. 28 Drop‐in models and after‐hours services, incorporating peer navigators, appointment reminders and the integration of primary and behavioural care diversified to include allied and complementary therapies, have been proposed to make primary health care more accessible.…”

Child Sexual Abuse, Alcohol and Other Drug use and the Criminal Justice System: The Meanings of Trauma in Survivor Narratives for a National Royal Commission

“…The impact of childhood trauma may confound the impact of problematic AOD use as it is difficult to disentangle their effects. Further, treatment services may be inaccessible to trauma survivors, either because services are rationed or unavailable; or because survivors' survival mechanisms, self-beliefs of unworthiness, or previous experiences of poor quality support and stigma mean that survivors are resistant or reluctant to undertake treatment, fear, or shame (Cortis, 2012;Moensted & Day, 2020) An important source of evidence on the impact of abuse in institutionalised care is autobiographical accounts from survivors themselves (Jones, 2019;Reynolds, 2012;Swain, 2015). These narratives are generated from diverse sources, including high profile investigations in several countries on the experience and impact of institutional abuse, at the hands of state and faith organisations including churches and schools (Gilligan, 2002;Hughes, 2012;McAlinden, 2013).…”

“…The impact of childhood trauma may confound the impact of problematic AOD use as it is difficult to disentangle their effects. Further, treatment services may be inaccessible to trauma survivors, either because services are rationed or unavailable; or because survivors’ survival mechanisms, self-beliefs of unworthiness, or previous experiences of poor quality support and stigma mean that survivors are resistant or reluctant to undertake treatment, fear, or shame(Cortis, 2012; Moensted & Day, 2020)…”