Series 8, Episode 4, Niamh Cullen on Stigma & Addiction

Join Dr Lisa Cherry and Niamh Cullen in conversation on stigma and addiction and why drug-related deaths are more often driven by exclusion, trauma and missed connection than by a lack of services. We trace how labels, “choice” narratives and system design quietly add harm, then map practical ways to build hope through relationships.

We explore: 

• Niamh’s career timeline from children’s homes to needle exchange, prisons, outreach and commissioning
• Writing a Safeguarding Adult Review after five street deaths and recognising lifelong trauma patterns
• Stigma as a public health issue that contributes to drug-related deaths
• How labels like “addict” erase strengths, roles and identity
• The “it’s a choice” myth and the double bind it creates
• Internalised stigma, shame and the impact on self-worth
• Why stigma can be subtler and stronger inside services than in communities
• “Engagement” expectations that ignore poverty and unstable housing 
• Treatment gaps, outdated pharmacology and the harm reduction debate
• What trauma-informed practice looks like in real contact; names, kindness, eye contact and reflective practice
• How austerity and policy shifts change culture, partnerships and the workforce
• The power of lived experience roles to rebuild trust and shift outcomes

Transcript

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Welcome And Series Focus

SPEAKER_01 0:03

This is the Trauma Resonance Resilience Podcast. This is for you if you are interested in compassion, connection, and relationships and how we can all work together creating services that do not add to harm but rather seek to support recovery from it. I'm your host, Lisa Cherry, and this is your time to sit back and listen in on conversations that make a difference.

SPEAKER_02 0:30

Welcome to the Trauma Resonance Resilience podcast for the new series where we are focusing on stigma. And today we're going to be focusing on stigma and addiction. Every episode that we're doing in this series will focus on one particular area today is addiction. And to join me in this conversation, I have got Neve Cullen, Public Health Partnerships Manager for Inclusion. And I will let her tell you more.

Neve’s Route Into Drug Work

SPEAKER_02 1:02

Hello, Neve.

SPEAKER_00 1:03

Hello, Lisa. So thinking about my career to date for context, I started off in the mid-80s working in children's homes, which I loved. I probably shouldn't have been there. Some of the kids were the same age as me. Long-term placements, everything you'd imagine. Probably not a great regime. When we look back at what we're learning about children's homes now and what was happening in the 80s, I always felt a bit odd and I was always called collusive, which I never see as a strength, but didn't at the time. I then went to London and I did my CQSW, which was then the social work qualification. And I did a probation placement because they paid you to become a probation officer afterwards. And when I and the eight reports I had to write were for drug users. And it blew my mind because, of course, I had to do the theory behind it when I was writing my essays and things. And I spent a lot of time in drug services. And after coming from a children's social care background, it was just fantastic because of the HIV epidemic in the early 90s. You had to work with people, you were given permission to find people however you could. I mean, it's interesting with the kind of toxic word engagement that we have these days. You were paid to engage however you could to get the messages out there to reduce the harm, probably when I look back to reduce the harm for the main population, not necessarily the drug users, but it was very refreshing and it certainly bit me then. And I then went on to do my second placement in one of the first needle exchanges, which again, as a concept, you know, it was fantastic. We'd have a woman's afternoon where we'd have older women that had been referred by their GP because of their benzoaddictions, where they'd been on strips for 20 years, and young girls just out of Holloway. And it was fantastic. You have the older women knitting clothes for the babies of the younger women. And I was absolutely sort of drawn to it. And then after that, I went to work in prisons. Um, so I'd worked in children's homes, drug services, prisons, then morphed into outreach services, hostels, working with people directly on the street, working with an organization called Mainliners at the time, which was run by people with lived experience for HIV-positive drug users. I'd often think we've forgotten everything we knew in terms of how we used to deliver services. And eventually worked in drug treatment. After a few years of doing that and starting a young family, I was advised that you better go back office because it's much better than taking the stress of the workforce home with you. And I applied for a commissioning post then, a drug and alcohol commissioners post, probably in the sort of late 90s. I've done that for years. I did that in London for years, moved north, I've done the same thing. Something very different happened with moving north. I'd always change job every few years. And I live in the area I work, and we're a small valley, we're like a bowl. People can't leave. It's very beautiful. But I have never had that experience of, you know, my neighbour's children being affected, getting uh maybe not always welcome feedback in the co-op, you know, going to my boxing class with people in recovery. And I found it really compelling, and I have found my sweet spot in terms of finding purpose and the meaning in my work.

Five Deaths And A Trauma Lens

SPEAKER_00 4:29

Anyway, in 2020, or a little bit before in 2018, for a very small area, we had five deaths on the street of people that we now call suffering from multiple disadvantages, but were known locally as drug users, and managed to persuade our safeguarding adults board that this required a SAR and that I could write it, which is quite unusual to be able to allow to be right to write a report. And I wrote, you know, obviously I got all the chronological information of these five men's lives, and I wrote the report. And I'd lie in bed and they're all under my bed. All the paperwork was under my bed, and I'd lie there at night just in horror, knowing that because of my age and our circumstances and their age at death, I'd walked their journey through the children's homes, through the prisons, through the streets. They were the same people. You know, I kind of from the work perspective, I really understood their experience. At the same time, Em was setting up the adversity, trauma, and resilience work through Calderdale.

SPEAKER_02 5:33

And my sister's Emmeline Irvin Irving, sorry. And she's also going to be coming onto the podcast at some point to talk about stigma and obesity.

SPEAKER_00 5:43

Brilliant, brilliant. And it somebody told me because for me, in all the reading and the writing, and it was a lot with five deaths, you know, and a lot of material to read, that it was trauma. That the whole thing was really about their management of their experience of trauma and our system's failure to respond to that trauma throughout their lives. And so that's where I became engaged with that work across West Yorkshire and setting up the adversity, trauma, and resilience work. And since then I've found a real the sweet spot, has got even sweeter because one of the things I did was spent quite a bit of time with peers of the men that died, and I really began to engage with that later in your career, revisit, you know, having the ability to engage with that lived experience. And for the last four years, I've cooked tea every Friday night for a large group of people with complex lives. And um, I argue that that's my, you know, continuous service improvement strategy, you know, that I know what has happened. And by having that privilege, and you know, by them welcoming me, I it has absolutely massively changed how we deliver services in Calderdale and how we commission. But they really feel that they influence. So to give you an example. So if I go down there at half past four to get tea ready, there might be, I don't know, four or five people saying, I'm late to get my script, I'm late to get my script, the service is shutting at five. So I put them in the car, take them to the service, and the staff would all be there with their bags packed ready to go at quarter to five, and the disappointment on their faces as I arrived with the next tranche. But over time, where I was very much an irritant, I think, for the provider for the first couple of years, we've really shared a journey together. And I think I hope that anybody walking into our services in Calderdale would feel that difference.

SPEAKER_02 7:37

Well, one of the things I am really interested in, what you just described, was a kind of timeline, a timeline of your own career. But you then mirrored that against the timeline of some of the people that you're working with. And I think I think that's quite interesting because I'm interested in thinking about that in the context of understanding more about stigma and thinking about how your journey would not have been stigmatized, but the very same journey by the other people would very much be stigmatized. What are your thoughts about that when you think about that journey that you've taken alongside people who some of whom I mean, I myself was in children's homes in the 80s. Yes. So um it was interesting, you know, I didn't need to tell you to hear hear about that. But also in terms of thinking about that trajectory that we know for some people is the trajectory that they will take because of system harm, inequity, inequality, and and all of those things. So speak to that for me a little bit, please.

Stigma As Public Health Harm

SPEAKER_00 8:51

Well, I think, you know, when I review drug-related deaths, and I think it was probably because I was thinking about of my final message, really. I rarely see people who because I constantly review deaths all the time anyway, as part of my job. I rarely see people who've died because services didn't exist. I think for me, that's probably one of the most compelling things. I see people that have experienced years of exclusion, disengagement, stigma, trauma, and missed opportunities to make those important connections. You know, I think that it really speaks to me of what isn't working. Yeah. And what we can do better. And, you know, stigma isn't just a social issue. You know, in the context of that, it's a really serious public health issue because I think it contributes to those deaths.

SPEAKER_02 9:37

Yes. And the whole approach to addiction is still this idea that the problem is in the person, that somehow the pro the person is the problem. And if the person stopped being the problem, the problem would go away. And that's one of the difficult things, isn't it? Because it's not treated as a public health concern, it's not treated as medication, it's treated as an individual deficiency where a person just does not have the ability to stop doing what they're doing. And in a way, that is the soil with which stigma grows, isn't it?

SPEAKER_00 10:16

Absolutely. And when I, you know, you talk about maybe they experienced stigma and I didn't. I've had a the later revelation, I've had lots and lots of problems and challenges at work. And I really understand now how there's an element of stigma being contagious, and that actually professionals that put themselves out there to try and make a difference expose themselves to all kinds of stigma. You know, that what I find really frustrating is I work really hard on boundaries, but people might watch me and not think I'm working in a boundaried way. In the community that I work with, they use the L word a lot, love. And I think it you can feel professional love for people and really feel differently. So the fact that we might be wandering off at the end of a Friday night session and people say, I love you, and you say I love you back, it actually diminishes you as a professional, you know. And it's and I think that there's something, and I see it with our best workers that people often think they're a bit edgy or a bit loose, but in fact, they're working hard to really connect and provide people with hope. So I do think that's another that was that's my later bit of understanding of stigma, really.

SPEAKER_02 11:28

So

Labels, Choice Myths, And Shame

SPEAKER_02 11:29

what do you think are some of the most common assumptions that people make about those living with addiction? And how do those assumptions affect people?

SPEAKER_00 11:41

Well, I think the first thing on that individual level, you know, we're reducing somebody to a label, an addict, a junkie, a crackhead, a drug user, you know, kind of we're and we're diminishing and not, you know, we stop seeing them as parents, as neighbours, as children, as workers, you know, all their all their strengths are completely diminished within that. So I think that's the kind of headline, really. Um, and the biggest thing is is that it's a choice.

unknown 12:10

Yeah.

SPEAKER_02 12:11

So there's this notion that's a double bind, isn't it? It's a double bind, it's a choice, yes, um, coupled with being reduced to an identity. Yes, yeah.

SPEAKER_00 12:23

Yeah, very much so. Very much so. And yeah, we don't, you know, we're not uh, you know, and it's back at that, you know, that fundamental thing, not looking at the full picture of what's in front of you, you know, what somebody brings with them, their past, their present, and their their strengths, you know, we just often seem to be completely blind to them. So I think that's the kind of for me, that's the sort of first level. Then I think there's something about the impact that has, where people internalise that stigma, you know. People always say, don't they, if you tell people something often enough, they'll they'll begin to believe it. So, you know, the stigma, the impact on self-worth and and feelings of shame and you know, all of those dreadful things that keep people unwell. Yeah. And, you know, it's creating distance all the time, isn't it? It's them and it's us and it's othering.

When Community Is Kinder Than Services

SPEAKER_00 13:17

Less so though. I have to one of the things that working in a small place and working in Halifax, we have a lot of these, you know, kind of community journalists on Facebook that will go to tents or go to people. You'll see it all over the place and and comment or, you know, about people drinking in squares. And what has been really heartwarming for me is that within the community, there was a post of a young man I know that's covered in tattoos and piercings last week in the square. There were 72 comments, of which 71 were absolutely loving and kind, and people adore him and they know him really well. And it's not always what you'd imagine. And in fact, I probably see more stigma in a service setting, which is more subtle and a bit more sophisticated these days than I do in the community setting. Tell me more. Tell me more. Well, I've thinking of this specific example, only last week where we've got a square where people will congregate and drink, and they don't use drugs in the open, it can get a bit loud and noisy. And most of the shopkeepers know everybody really well, you know, and enjoy them and give them tick, and you know, they're part of the fabric of that community. What's very different for me here, Lisa, I think that maybe I should qualify a bit, is it's very different in these small towns in the north. So if you're begging outside the bank, you might be begging to your school teacher or your neighbour or your auntie or your uncle. There's not the anonymity that you have in big cities, so it is slightly different. So people know each other well. Now, my daughter has just started to work in a cam service. That the windows open out onto the square below, and in the hot weather of last week, the windows would be all open. She's been there a month. She's absolutely horrified at how people are spoken about.

SPEAKER_02 15:11

Yeah.

SPEAKER_00 15:11

And, you know, I mean, one of them, he has the most horrendous ADHD, he's in his 40s, and he drinks, you know. If those services, well, whether they'd have been any effectiveness, but he didn't have the opportunity to have that support. And their first kind of that service will call the police for no reason other than them, you know, and it's that kind of thing, but this is really ironic. Gita that's running the shop, it's absolutely fine with it. But these professionals that go home at night, arms, you know.

SPEAKER_02 15:39

I I mean, I believe you, and I believe you because I remember delivering some training nearly 10 years ago now, and I was in a setting, it wasn't NHS setting, it was a public health setting with adult services, and there were people there who were specifically there in drug and alcohol services who said things that I I literally had to sit down. I was so disturbed and upset by people who I believed would share similar values and understandings to me. Said definitely bought into the choice factor. Some of the alcohol services you couldn't even access unless you weren't unless you weren't drinking. Yeah. Which is is about as bizarre as it gets. Um and there were derogatory terms used about people, and that was in the services. And and naively maybe, but I was shocked. It's shocking. It is shocking. I was shocked because you know, you kind of expect societal stigmatization about a whole range of things because we understand what kind of society we live in. And we see it playing out on media. I mean, you know, we had a long period of people living in poverty being absolutely demonized on you know, and uh we don't see that so much now, but I think we had a year of relentless program after program mocking people living with inequity and equality and poverty. But to go into a work setting and meet people doing that to people suffering and self-medicating their distress was quite shocking. And actually, I don't think I was my best training self because I was so affected. Affected. Yeah, yeah, yeah. And I also there was about 80 people in the room, so calling stuff out 10 years ago was much harder than it would be for me now. Of course it is. I know.

SPEAKER_00 17:57

So yeah, and I think there's nothing better than aging as well as experience at least in your space.

SPEAKER_02 18:03

There's nothing better than menopause of freeing. There's nothing better than aging, but also it's about experience of holding spaces and using what's in the room as material and being able to call in some of those things in ways that are not also shaming then to other people, because that is not the intention either. It takes a bit of thinking about, and because that hadn't happened to me before, I didn't have any kind of template to draw upon in terms of how to deal with that at the time. That wouldn't be the case now. But it's shocking. Yeah.

SPEAKER_00 18:38

And

Engagement Barriers Built Into Systems

SPEAKER_00 18:39

then if you think about so that's the more explicit stigma, but then how a lot of the agencies run that we need to work with, thankfully not our drug service at the moment, but when you're starting to try and engage with the necessary mental health support or adult social care, adult social care support, you know. First thing is engagement. This concept of engagement, and that's all on the onus for that. This is what I don't understand as switched. It's all about, if it's me and you, it's all about you, Lisa, engaging with me, not the other way around. I find it really bizarre. But then no acknowledgement of the practical structures. I mean, most of the people I work with, for half the month, their mobile phone will be in cash converters, you know, that they haven't got stable addresses, you know, the how they manage their day and night with earning money to engage can be really difficult, but we don't, it's how we work out how to do that best. And then consent, you know, people that have been traumatized by childhood interventions with the states, you know, kind of no understanding of where that might get in the way and what we can do about that. And then just things like opening times, the hoops you're meant to go through, waiting, you know. I just think the whole thing is set up. And then if you could zoom out a little bit, you know, you think about treatment and drug and alcohol treatment. Well, we've got no new pharmacology. We've got no new pharmacology because we're terrified of giving people what they want. I mean, people, methadone is the only benefit I'm learning in later years about methadone is it is a trauma drug. Because as we try and use other substances like subtexabuvidile, people are, you know, they really, unless you've got the right environment and support around you, managing those feelings can be really, really challenging. But I'm sure we could have something more refined for that than methadone. And I think of diabetes, I think of all the other bits of healthcare. There is no way we'd be sitting still using 1950s medications. No. It's bizarre, isn't it? But so it's that, you know, in terms of a system, the stigma is really bedded in into how we do it. The only heroin-assisted treatment that we had in the north of England was completely bound by criminal justice. You know, not health. So I think there's, you know, there's the there's what we experience on the day-to-day in the service, and then but the whole thing in itself is kind of enshrined. We won't give people safe places to use drugs, you know, it's just absolutely shocking. So I think it's really embedded in the fabric of it all.

SPEAKER_02 21:20

And I guess that's why thinking about stigma and addiction is so important, because all of that I would argue is because of the stigma of drug use.

SPEAKER_00 21:30

Exactly. That's what I would say. It's be there's a fundamental thing where, you know, it's a choice, so we shouldn't be giving them what they want. It's that core kind of, you know, really simplistic, not to be seen to, you know, because we don't see it as a health need, we don't see it as a trauma response, we don't see it as self medication, we see it as a flaw.

SPEAKER_02 21:54

So, what kind of changes do you think in everyday practice?

unknown 21:59

I mean.

SPEAKER_02 22:00

Really, I suppose what we've looked at there, we've looked at system harm actually. Yes. Looked at stigma within society, we've looked at system harm, and you know, there's also individual practice. What kind of things do you think would really make a difference?

Hope, Connection, And Reflective Practice

SPEAKER_00 22:19

It's all about hope, connection, and relationships, that it's so important. They are the absolute cornerstone for me. And you know, when we're talking, I had to I did some training with housing last week, and because what they were asking for was they were saying we've all done trauma informed, but nobody's telling us how to do it. And it's such a little switch, isn't it? You know, we talk in West Yorkshire about trauma and putting your sunglasses on, you know, that that that work, and you know, you have to free staff to be able to feel. So I think one of the absolute cornerstones, which we all had as regular practice, you know, 20 years ago, is good solid reflective practice, you know, how we keep people well, how we enable them to use the tools of self and not be shy of that. And then how that plays out in human contact, you know, eye contact, knowing people's names, kindness. And, you know, the classic that you know we'll all talk about is, you know, not what have you done, you know, kind of what has happened to you. But it's not about spending lots of money, is it? It's about these shifts and permission for those shifts. The strength of your outcome should be the strength of your relationships and that continued engagements, you know. What changed in the last 20 years? Why, why have we more than 20 years? Yeah. I don't know. Because I look, I mean, the services have disappeared, a lot of services, a lot of third sector services. One of my kids is working with uh young men selling sex at the moment, and there's nothing. And I was thinking, oh my god, I used to be able to rattle off three or four, you know, services for young men selling sex, run by people with lived experience, with showers and washing machine, all that's gone. So I think structurally, the change in the landscape of services has been.

SPEAKER_02 24:13

So the ideology of austerity, the the reduct the reduction of public. So that's the republic of that. And I guess that's 15, 16 years, isn't it? So that's why I was curious about you saying 20 years. I was thinking, I wonder, isn't it else?

SPEAKER_00 24:27

I think it's changed a bit before that as well. And I'm kind of thinking, I'm not sure. I think that the thing about austerity, which it did to your wider partnerships as well, is gatekeeping mode. You know, I kind of one of my, you know, I often think, oh, do you people knock too lightly on doors? Do you want them to open them? There's something about kind of that tenacity, you know, and maybe, and also there was a shift, and I don't know where this has come, and it is about all the responsibility, and maybe it's in the drug spit of the world particularly, is all the onus for this to work is on the service user. There's nothing about that alliance, you know. I was trained in, you know, we talked about therapeutic alliances in the 90s where people just have no notion of that sort of work anymore. We've got very little psychosocial stuff going on. The other thing I think happened, and I think this is maybe where the 20 plus years come in.

Policy Shifts And Workforce Culture Change

SPEAKER_00 25:28

So for the drugs field, it was very small. And when I started, it was almost entirely lived experience or people with very fancy therapeutic counseling qualifications. And as a non-user, I had to work really hard, do loads of volunteering to get a job in the field. Now, when I went off on maternity leave, so that would have been 19-ish, um, dip came about, which was this huge amount of um government money into the drugs field, all based on criminal justice. But suddenly there was loads of jobs. And, you know, respectfully, and it's just how it pans out, when I look at somewhere like Halifax, when all those jobs came out, it wasn't people with a vocation and it wasn't people with lived experience. Suddenly the workforce really expanded, and it was people that used to sell double blazing or used to do other things. And I think there was a lot of therapeutic value lost.

SPEAKER_02 26:26

Yes.

SPEAKER_00 26:26

I think that might that feels more than just the austerity, but I think the culture started to change because uh because of the people that were being attracted. Because, you know, you didn't have to have qualifications, it's a really good starting salary. I'll never forget coming back from maternity leave and going to Houndslow Police Station to see the new dip team in action, where there was a young woman wearing a short skirt and high heels with a clipboard, and she was knocking on cell doors, going, Hi, I'm Suki. Does anybody want to see a dip worker? And I was just like, What's happened? And that changed then. So I think there was some sort of cultural change then. What is fantastic with me, the big movement in recovery, which we stuck with in Calderdale, is that we have a really good, solid lived experience workforce in our recovery world, who we've managed to manipulate being the landlord of the major provider. So they've got quite a bit of autonomy and power. And because we're a small place, we're now up to 20% lived experience in our main treatment provider because of the coexisting model. And that that is where we're really seeing change in culture and the relationships of people. So I think the motivation for doing the work is really important.

SPEAKER_02 27:48

Yeah.

Why Relationships Get Squeezed Out

SPEAKER_02 27:49

And I guess just as we kind of come to a close, what changes would you like to really see going forward? Because you've described a lifetime's career. I'm I'm 56, so I I kind of I'm not quite at 60 if I get there. Um, I'm I I have some health issues, but um, so I don't know is is the truth, but I'm very much aware of what that trajectory looks like and having that opportunity to reflect back and to see different policies and how policy shapes the work that we do. You know, it's it's so important to me that people stay working for for as long as possible in the nicest possible way, just so that there is that kind of you know, understanding of what's been and how things are different and what we can use that we used in the past that work and to have that rather than people just you know almost thinking this is how it's always been, because no area that I've worked in hasn't changed fundamentally, uh, and that's what you're describing.

SPEAKER_00 28:56

So worse, Lisa has I mean, we seem to just be losing, and like you know, I don't know how much of that is also mainstream culture, you know, there's something about empathy and compassion.

SPEAKER_02 29:09

Well, also relationships. I mean, you've spoken a lot really about how it's a one-way street, that that relational practice isn't really, you know, a big aspect of that. And I guess that's a really important part of my work in in different settings that I work in is around relational practice and relationships. But there's also something about efficiency. Relationships are not efficient. Uh, relationships are very much time-consuming. They work, they require a lot of reflection, they require repair when there's been rupture, they require a lot. And I wonder if there's something about that as well, that this idea that you can almost, you know, diminish that relational work to something much more efficient.

SPEAKER_00 30:02

But you see, I think you can exploit that language of outcomes.

A Magic Wand For Joined-Up Care

SPEAKER_00 30:08

Because I mean, you know, if I had a magic wand, if I really had a magic wand, and next week I could make big, big changes in the local authority, what I'd do is I'd go in and I'd say, right, down tools for two weeks. Let's look at our systems, let's look at everybody you're working with in children's, let's look at everybody you're working with in adults, and let's look at our bits of the world as well. We'd probably come up with a hundred families. I the relationships in these, you know, small places are so easy to see. And then I'd say, and how much are we spending? We could add up how much we're and the and then separate that into negative and positive spending, can you imagine? And then I'd find these great pod teams of former reformed workers, and I'd say, okay, we'll divvy up these families, we'll divvy up the money, and you can go and knock on the door and say, how can we help change your family outcomes? It's never gonna happen, is it, Lisa? That's what I kind of it's so frustrating to see, you know, that you just it the system's fragmented, it works against each other, you know, people aren't working together. Um, we could do so much better and we could save money. I think that's the other thing. And I think really sad one of our ways through some of this is the costings work is to couch that negative spending. And then the next, yeah, and how you bring systems together. So I'm you're not just the police aren't saying, well, I'm not playing ball because you're only saving money in adult social care, where we begin to work in place of systems and we really look at how we support each other's outcomes. That would be my that would be my perfect world. But that's lovely to happen.

SPEAKER_02 31:53

I love it. Let's do it. Let's do it. I love it. Listen, Leave, it's been great talking to you and for really nice to meet you.

SPEAKER_00 32:02

So I've read lots of bits, so I feel quite privileged a bit in awe.

SPEAKER_02 32:06

Oh, thank you, and thank you so much. It's it's an absolute pleasure.

Final Thoughts And Listener Request

SPEAKER_01 32:14

You've been listening to the Trauma Resonance Resilience podcast with me, your host, Lisa Cherry. Brought to you straight from the heart of the knowledge that high quality relationships are the cornerstone of learning, healing, and growing. If you've enjoyed this episode, please consider sharing or reviewing. Until next time.