Substance Use Stigma As a Barrier to Treatment and Recovery

Introduction

Stereotypes and judgments about people with substance misuse problems are extremely prevalent and negative. The content of these stereotypes varies, with examples including “people who use drugs are immoral,” “alcoholics are unreliable,” or “addicts are dangerous.” These negative evaluations are held not only by those who abstain from substance use, but also by those who themselves use and abuse substances. As the criminalization of drug use has increased over recent decades in the United States, the level of negative attitudes toward drug use has also increased.

Although the exact form of these stereotypes and judgments may vary across different substances and social groups, substance misuse appears to be at least as stigmatized, if not more so, as psychological disorders such as depression, schizophrenia, or borderline personality disorder. The data about the prevalence and negativity of stigmatizing attitudes are clear; research to date on the links between these attitudes and subsequent negative outcomes for those with substance addiction is relatively sparse. Because the body of data on stigma toward the mentally ill is much broader and deeper, especially for psychotic disorders, this chapter depends somewhat on extrapolation from mental illness stigma, to substance abuse stigma.

A review of sociological and historical analyses of factors that have contributed to the stigma of substance abuse is beyond the scope of this chapter. Other authors (e.g., Read et al. ) have provided excellent narratives on such topics as the history of legal policy toward substance use and how larger values systems such as Puritanism contribute to stigmatization. Instead, this chapter focuses on the nature of stigma and its impact on individuals with substance abuse problems through review of scientific research and theory. In addition, we discuss implications for interventions regarding stigma, particularly in the context of the substance abuse treatment system. The chapter begins with a short review on the nature of stigma in general, followed by a focus on stigma as directed toward those using or abusing substances.

What Is Stigma?

As with most other common language terms that have been adopted by the social sciences, the concept of stigma has been difficult to narrow to a single definition. As used conventionally, stigma refers to an attribute or characteristic of an individual that identifies him or her as different in some manner from a normative standard and marks that individual to be socially sanctioned and devalued. One of the most widely cited definitions of stigma comes from Goffman, who saw stigma as an “attribute that is deeply discrediting.” This attribute affects the perceiver’s global evaluation of the person, reducing him or her “from a whole and usual person to a tainted, discounted one” (p. 3). Another influential definition comes from Jones et al., who suggested that a stigmatized person is “marked” as having a condition considered deviant by a society. Through an attributional process, this mark is linked to undesirable characteristics that discredit the person in the minds of others. Perhaps one of the most comprehensive definitions of stigma comes from the work of Link and Phelan, who define stigma as occurring when the following processes converge: (1) people distinguish and label human differences; (2) dominant cultural beliefs link labeled persons to undesirable characteristics that form a stereotype; (3) labeled persons are seen as an outgroup, as “them” and not “us”; (4) labeled persons experience status loss and discrimination that lead to unequal outcomes; and (5) this process occurs in a context of unequal power distribution, where one group has access to resources that the other group desires.

Types and Levels of Stigma Toward Substance Abuse

The preceding section was only a brief overview of the vast literature on stigma, stereotyping, and prejudice. In contrast, the rest of this chapter focuses specifically on stigma toward addiction and begins with a review of types and levels of stigma in relation to substance abuse. Stigma can be subdivided into various types and levels. One distinction can be made between structural and individual stigma. Structural or institutional stigma refers to macroscopic patterns of discrimination toward those with substance misuse that cannot be explained at the individual psychological level alone. This kind of stigma can be either intentional or unintentional. Intentional stigma refers to the rules, policies, and procedures of private and public organizations and structures with power that consciously and purposely restrict rights and opportunities of the stigmatized group. Intentional structural stigma toward addiction would include laws and tax codes that provide inadequate levels of funding for addictions treatment compared to other health conditions or harsher sentencing laws for crack cocaine versus powder cocaine. In contrast, unintentional stigma refers to instances where rules, policies, or procedures result in discrimination, seemingly without the conscious prejudicial efforts of a powerful few. Examples of unintentional structural stigma might include the lower wages and poorer benefits paid to substance abuse treatment professionals compared to other health care or mental health care workers, thus potentially resulting in poorer quality care. Another potential example of unintentional structural stigma would be the exclusion of substance abuse treatment benefits from the Mental Health Parity Act of 1997, resulting in less accessibility of addiction treatment services. This exclusion continued until 2008, when the Mental Health Parity Act of 2008 included substance use disorders.

It is conceivable that prevalent negative attitudes toward substance abuse might contribute to institutional practices that typify structural stigma. For example, prevalent attitudes that people who are addicted to substances are blameworthy and not likely to recover from addiction might make it less likely that the public would be supportive of spending a portion of their tax dollars on treatment. This phenomenon has been witnessed in a German sample who reported that during periods of economic difficulty, they would prefer to cut funding for mental illness and addiction treatment before cutting funding for physical problems.

At the individual level, stigma can be broken down into two types : public stigma and self-stigma. The most obvious form of stigma is public stigma, which refers to the reaction the general public has toward the stigmatized group. This includes stereotypes and attitudes toward the stigmatized group, as well as acts of discrimination, termed enacted stigma. For example, rejection by a friend following discovery of a person’s substance abuse history, denial of a job opportunity because an employer suspects an applicant is in recovery, or disparaging remarks about people with addictive disorders would all be examples of enacted stigma. People abusing substances and those in recovery frequently encounter enacted stigma. Enacted stigma has been clearly associated with a number of adverse outcomes in mentally ill populations. Although data demonstrating direct links between encounters with enacted stigma and negative outcomes are less available in substance-misusing populations, data showing more negative social attitudes toward substance abusers than those diagnosed with schizophrenia suggest that enacted stigma is even more severe toward those abusing substances.

The second type of individual level stigma is that of self-stigma, which refers to difficult thoughts and feelings (e.g., shame, negative self-evaluative thoughts, fear of enacted stigma) that emerge from identification with a stigmatized group and their resulting behavioral impact. For example, a person with substance abuse problems or a person in recovery might avoid treatment, not apply for jobs, or avoid intimate social relationships because, as a result of self-stigma, they no longer trust themselves to fulfill these roles or fear rejection based on their substance-using identity. Among populations with serious mental illness and dual diagnoses, self-stigma has been associated with delays in treatment seeking, diminished self-esteem and self-efficacy, and lower quality of life.

Perceived stigma is a component of self-stigma and refers to beliefs among members of a stigmatized group about the level of public stigma in society (cf. Parcesepe and Cabassa ). A result of perceived stigma may be that people may limit their actions (e.g., seeking treatment or acknowledging their own struggles with recovery) in an attempt to avoid stigmatization. Some data are available showing that perceived stigma may serve as a barrier to treatment adherence, at least in some groups. At least one cross-sectional study of stigma in addiction has generated empirical support for the conceptual distinctions between public, perceived, and self-stigma.

The Need to Study Stigma in Context

Despite the volume of available research on stereotyping, prejudice, discrimination, scapegoating, social categorization, and social deviance, the amount of stigma literature relating these processes specifically to substance abuse is quite sparse. Ahern has suggested that this hole in the literature may result from the common perception that stigma and discrimination against drug users serves to deter drug use and that the possible negative effects of stigma are relatively minor compared to the deterrent value of stigmatization. A substantial body of literature from a law enforcement and criminal justice perspective views stigma as a positive form of social control that discourages illegal activity. This literature largely ignores the potential negative effects of stigma. In contrast, most of the professional literature from mental health and recovery perspectives views stigma as negative and in need of reduction. This literature seems to largely ignore the possibility that stigma might have beneficial effects in some contexts. Each of these perspectives seems to minimize the importance of context and neither seems to acknowledge the possibility that stigma may have both beneficial and harmful effects, depending on the context in which it is found.

A comprehensive scientific approach to stigma would involve examination of the phenomenon across the myriad of situations in which it occurs. Stigma is a complex phenomenon with many forms and widely varying impacts on the individual. Prior to initial drug use and throughout the developmental trajectory for addition and recovery, stigma may have various possible functions. For example, stigma may affect some individuals who are currently not using drugs by dissuading them from initial use. On the other hand, individuals who identify with marginalized populations may actually be attracted to drug use because of its marginalized status. Once a person has bypassed barriers to initial drug use, stigma could serve to further reinforce and isolate drug-using subcultures, further supporting consumption. For many, stigma serves as a barrier to entering treatment because of fear of being labeled and stigmatized by others. For others, experiences of being stigmatized and judged by others once drug use is discovered or labeled as problematic might serve as a motivator for treatment entry. The effects of stigma might change again after a person enters treatment. Individuals experiencing more self-stigma or who are more fearful of enacted stigma may stay in treatment for longer periods, perhaps benefiting more from treatment. On the other hand, the impact of self-stigma may impede recovery by reducing the motivation of substance abusers and creating negative beliefs about their ability to recover, thereby resulting in earlier relapse. Some people may be relatively unaffected by stigma, perhaps because of personal conditions that help guard against its impact (e.g., financial resources), or because they do not identify with a stigmatized group. Finally, ongoing experiences of stigma-related rejection may serve as a barrier to reengagement with healthy, non–drug-using social relationships, returning to work, or obtaining a reasonable living arrangement. This array of possibilities suggests that simple judgments about the goodness or badness of stigma may be insufficient in understanding the role of stigma in initial drug use, the development of addiction, and recovery from substance abuse. Given the potential complexities, we need a contextually situated approach to examining the effects of stigma on drug use and related outcomes in order to maximally benefit all involved.

Straying from the hypothetical scenarios described in the preceding paragraph, a study by Farrimond nicely demonstrates the contextual nature of stigma’s impact. Qualitative analyses of reports from tobacco smokers in the United Kingdom showed that smokers from lower socioeconomic status groups were more likely to internalize smoking-related stigma and feel badly about themselves for smoking, rather than change their behavior to avoid it. In contrast, smokers from higher socioeconomic status groups were less likely to internalize smoking-related stigma and were more likely to have the resources to change their behavior to avoid being stigmatized. The authors suggested that this finding was a partial explanation for the much higher rates of smoking found in lower socioeconomic status groups. They hypothesized that broad-scale campaigns to stigmatize smokers might reduce smoking in persons from higher socioeconomic status brackets who would work to avoid it, whereas individuals in lower socioeconomic status may not be responsive, and furthermore, that such campaigns may even impede efforts to stop smoking because of increased internalized stigma. They argued that intervention efforts promoting stigma could actually exacerbate disparities already present between higher and lower status groups.

Thus far, this chapter has outlined the nature of stigma in general, including its types and levels. It has outlined how stigma is a complex phenomenon, the effects of which vary by context. The remainder of this text is more focused specifically on what is known about the stigma of substance abuse specifically, describing its importance for those individuals with substance abuse problems, information about stigma in families and social networks of those with addiction, stigma in the treatment system, and interventions to change stigma.