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.
Stigma Depends on Basic Verbal/Cognitive Processes
Stigma is always in the eye of the beholder. At a psychological level of analysis, all the preceding definitions hinge on the role of the cognitive and emotional responses of the perceiver in determining who is stigmatized. Stigma emerges from some of the most basic functions of language and cognition, such as categorical, evaluative, and attributive processes. As verbally able humans, a common cognitive activity is evaluating and classifying the people in our social world. This is particularly common when a lack of extensive personal experience with someone leads us to rely on cues for assigning that person to a social category, whether accurately or inaccurately. Our ability to classify according to socially defined categories is universal among language-able humans and also unique to us as a species. Just try it out for yourself. Read the following sentences and fill in the blank:
Men are _______________.
Women are _______________.
Alcoholics are _______________.
Gays are _______________.
Addicts are _______________.
Were you able to fill in those blanks? Even if doing so felt uncomfortable, most people are able to provide responses that seem to describe the group in question. Answers may readily appear even when they are unwanted or disagreeable. Anyone who participates in a cultural/verbal system learns common stereotypes for the groups that have been defined in that culture, whether they agree with them or not.
Throughout a typical day we classify people into groups based on some identifying characteristic or behavior, make judgments about what this means about them, and respond based on this judgment. Much of this process of stereotyping and responding occurs outside of our normal awareness and is harmless, even adaptive. For example, we identify the person at the checkout counter in the grocery store as a clerk and proceed to have them scan our groceries. Research has shown that stereotypes help to reduce the burden of problem solving in complex social environments (e.g., Mann and Himelein ). We are able to quickly develop evaluations and expectations of individuals based on their perceived membership in a group about which we have some social knowledge (i.e., stereotypes ). These stereotypes allow us to predict that person’s behavior and act accordingly. Sometimes this is quite useful, such as when purchasing items in a grocery store. Sometimes it is less so; for example, when seeing a bumper sticker on a person’s car endorsing a disliked political candidate, we may make unsavory assumptions about the driver and may be more inclined to engage in discourteous behavior on the road. Sometimes this process is clearly harmful, for example, where culturally sanctioned stereotypes devalue certain individuals and this same process results in stigmatizing, rejecting, and even discriminatory interactions. Through this process of objectification and dehumanization, we fail to appreciate the complex, historical human being and respond to the person solely in terms of their participation in verbal categories.
Stigmatizing Thoughts Are Resistant to Change
Stigmatizing thoughts and attributions have been shown to be difficult to change through direct intervention. One reason for this may be that judgment and stereotyping are massively useful for the individual in many social situations and thus are highly prevalent and automatic, often happening without awareness. In addition, verbal/cognitive networks, once formed, tend to maintain themselves. Stereotype disconfirming information that occurs during social interactions tends to be forgotten if the new material conflicts with older stereotypes. People tend to infer stereotype-congruent behaviors to dispositional causes, whereas stereotype-incongruent behaviors are inferred to situational causes, thus further supporting their already existing stereotypes. Even people who exhibit low levels of prejudice know the common stereotypes of stigmatized groups, and once learned, these stereotypes do not go away. If a person learns new ways of thinking, the old ways of thinking do not disappear, but rather are available to reemerge if the new ways of thinking are frustrated or punished (e.g., Wilson and Hayes ). Thus if new stereotypes are learned about a group, these generally do not replace the old stereotypes; rather, the new learning is metaphorically layered over the old learning. The old stereotypes are still available to reemerge under situations in which the newer learning is put under strain.
Stigma Is Sustained Through Cultural Practices
Although stigmatization is a universal human phenomenon, what is stigmatized has been shown to vary over time and across cultures. This suggests that stigma results from cultural practices that exist on the basis of their past ability to facilitate the survival of that culture, much in the same way that genes are selected based on their contribution to the survival of a species. Cultural practices that support categorization and stereotyping facilitate membership in and favoritism toward a perceived in-group (e.g., Hilton and von Hippel and Starr et al. ), as well as the resulting mistreatment of individuals in a perceived out-group. These distinctions preserve and sustain a variety of cultural practices when they generate advantages for the in-group, even when the groups are based on arbitrary characteristics bearing no direct adaptive value. Although stigmatization is defined as the behavior of an individual, it is always generated and sustained by cultural practices that reinforce and support stigmatizing attitudes, stereotypes, and actions. Thus in order to change stigma, it is important to change both the behavior of individuals and the cultural practices that support stigma among individuals of that culture.
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.
The Impact of Stigma on Individuals With Substance Abuse Problems
Self-Stigma
The psychological impact of stigma on the individual can be described under the term self-stigma. Self-stigma can be defined as shame, evaluative thoughts, and fear of enacted stigma that results from an individual’s identification with a stigmatized group and serves as a barrier to the pursuit of valued life goals. The dominant stereotypes about stigmatized groups are widely known in a given culture. Self-stigma comes about when a person first sees himself or herself as a member of a stigmatized group; now the negative stereotypes and biases of society that used to be about someone else apply to the self. For example, at the point when the person who misuses substances identifies himself or herself as an addict, relevant stereotypes (e.g., addicts are irresponsible) that once applied to another now apply to himself or herself. To the extent that people believe this stereotype, they are likely to impede their own chances for success, for example, by not applying to jobs that would require them to be responsible. Because the dominant stereotypes of marginalized groups are largely negative and devaluing, self-stigma may further increase the shame that often comes with addictive behavior that violates important societal and personal values and norms.
A second component of self-stigma is the fear of enacted stigma. Out of this fear of being the target of stigma a person might avoid treatment in the first place or might not get needed social support that could come from disclosing their concerns to trustworthy others. People with substance abuse widely report fear of stigma as a reason for avoiding treatment. Less evidence is available for other effects of self-stigma in addiction, but self-stigma in mental illness has been associated with delays in treatment seeking, diminished self-esteem/self-efficacy, lower quality of life, early dropout from treatment, poorer social functioning over time, and increased depression at follow-up.
Coping and Self-Stigma
Much of the harm of self-stigma comes not only from the presence of shame, painful self-evaluations, or fear of stigmatization, but also from understandable yet costly attempts to cope with these difficult thoughts and feelings. For example, when people who identify with a stigmatized group enter situations where they perceive the potential for devaluation based on this identity, they often expend energy searching for and defending against this perceived threat. The effort is taxing and distracts the individual in ways that might hinder social or intellectual performance. In a recent test of this idea, Quinn et al. found that individuals with a history of mental illness who revealed this history prior to taking an intelligence test had poorer performance compared to a control group who did not relate their history of mental illness. These results are in line with more general findings on stereotype threat, that is, that people perform more poorly in situations where a specific stereotype about the group of which they are a member applies. Specifically in relation to substance abuse stigma, these findings suggest that when people with a history of substance abuse problems are in a situation in which addiction-related stereotypes might apply, they may perform more poorly than they would in situations unrelated to addiction-related stigma.
People also cope with stigma by withdrawing their efforts from or disengaging their self-esteem from domains in which one’s in-group is negatively stereotyped or in which they fear being a target of discrimination. In an attempt to cope with the potential judgment, failure, or shame that might result from confirming a stereotype, a person may exert less effort in domains of living that relate to relevant stereotypes. For example, a person who identifies with the stereotype that alcoholics are immoral might not engage with spiritual or religious groups out of fear that he or she might be judged by others for their moral weakness. Unfortunately, when a domain is one that might be part of living well (e.g., a steady job) and is likely to elicit thoughts of common stereotypes (e.g., “they won’t hire an addict”), then disengagement from that domain (e.g., not looking for work) is likely to interfere with recovery.
Whether a stigmatizing mark can be concealed is also a relevant variable to how people cope. For example, some stigmas may be relatively concealable, such as a past felony conviction or a history of depression, whereas others may be quite difficult to conceal, such as obesity or diseases with obvious physical characteristics. For many people with substance abuse problems, their condition is concealable, whereas for others it is less so. Another way to think about concealable stigma is the distinction between “discredited” versus “discreditable” individuals. For individuals with a concealable stigma, a common occurrence is deciding with whom, where, and when to disclose the stigmatizing identity. Whether disclosing a stigmatizing identity is helpful or harmful is likely to be highly dependent on context. In some cases, through disclosing a stigma a person may be able to obtain social support or direct assistance from treatment agencies or health care professionals. Revealing a secret to a trusted confidant has also been shown to be related to a number of psychological benefits, including improved psychological and physical health. On the other hand, disclosure of a stigma could result in social rejection and isolation, the loss of a job, rejection by family members, judgment from treatment professionals, or disappointment that others were not more helpful. Research on secrecy as a method for coping with the stigma of addiction is relatively scarce and what exists is somewhat crude, typically examining secrecy as a generalized tendency in response to the fear of stigma, rather than examining the patterns of disclosure and how they might interact with social context. As a general rule, the use of secrecy and withdrawal from others as a coping mechanism has been associated with negative psychosocial outcomes. However, this general pattern should not be overgeneralized, as a recent large study of mostly minority drug users found that talking with friends and family about being stigmatized and judged was associated with poorer health outcomes. One difference between the Ahern study and other studies of stigma was that Ahern specifically focused on discussions of being stigmatized, whereas most other studies examined the tendency to keep substance use a secret. This suggests that the content of what is disclosed may also affect the likelihood of a positive outcome from disclosure.
All of the coping processes described above (i.e., searching for potential threats, withdrawing efforts from valued domains, and secrecy) could be seen as forms of a broader process termed experiential avoidance. Experiential avoidance refers to the attempt to avoid, control, or reduce the frequency of difficult or painful emotions, thoughts, memories, or other private experiences. Experiential avoidance overlaps with several closely related concepts, including lack of distress tolerance, cognitive and emotional suppression, and emotion/avoidance-focused coping. As a broader pattern, experiential avoidance has been shown to contribute to a wide range of psychological and behavioral problems, including substance abuse, depression, anxiety, psychosis, and burnout, among others. Because experiential avoidance has been shown to be modifiable through mindfulness and acceptance-based interventions, teaching mindfulness and acceptance may be helpful in coping with stigma.
Multiple Stigmatized Identities
For a person with substance abuse problems, the stigma of substance abuse is often only one of several stigmatized identities. Each stigmatized identity is layered on top of the other, creating a dense web of ideas about the self that must be managed and responded to, depending on the social and personal contexts. For example, substance abuse disorders are highly comorbid with other psychiatric disorders, meaning that the majority of people in treatment for drug abuse also have to contend with the stigma of mental illness. Many people in addiction treatment are also sexual or racial minorities. They may have a stigmatized medical condition such as hepatitis or HIV. They are frequently poor or homeless, both situations that carry their own stigma. Women who abuse substances are often assumed to be promiscuous. Many people with substance abuse histories also have had problems with the legal system or have been incarcerated. In addition to the stigmatization that people may experience directly from the legal system, they now have the added stigma of a prior conviction. Each additional stigmatized identity increases the chance of stigmatization. Each layer of stigmatized identity carries its own challenges that make it even harder to cope with the stigma of drug addiction.
In addition to the problem of multiple stigmas, the impact of substance abuse stigma can also compound existing social inequalities. For example, the stigma of substance abuse has disproportionately impacted the African American community in the United States, whose drug-related incarceration rate far outstrips their comparative prevalence as drug users. Because many in treatment for addiction are relatively poorer, the stigma of drug abuse that tends to fall on individuals in treatment will also tend to further reduce the life chances available to those who are experiencing poverty. Again, in addition to the direct effects of the stigma of addiction, stigma also tends to exacerbate the effects of already existing prejudice, marginalization, and disadvantage based on other identities.
Stigmatizing Attitudes and Behavior of Friends and Family
Supportive, cohesive, and noncritical social networks predict good outcomes in addictions treatment, whereas conflict with several members of a social support network, interpersonal conflict, and isolation predict poor treatment outcomes. People entering treatment for addictive disorders are often marginalized, with few connections to family, friends, or coworkers. Entering treatment may be a marker for having exhausted their “moral credit” with employers and families. Stigma may contribute to poorer outcomes by further contributing to the disruption of social ties and increasing isolation beyond the problems created through the direct impact of addictive behavior. Some data are available that bear directly on this point. A recent study of primarily minority drug users found that discrimination and stigmatizing interactions from family and friends was common and independently associated with poorer mental and physical health.
Stigma appears to degrade social networks over time. In one longitudinal study of people with mental illness, many of whom also abused substances, perceptions of stigma were associated with reduction in support from nonhousehold relatives over time. Stigmatizing attitudes and behavior of friends and family may also reduce treatment adherence. A recent study of individuals taking antidepressants for depression found that stigmatizing caregiver attitudes predicted premature discontinuation of treatment.
Family members of substance abusers may also experience “courtesy stigma.” Courtesy stigma refers to the tendency to devalue and stigmatize people who maintain or enter relationships with those in the stigmatized group. For example, in a study by Barton, parents of adolescents who abused drugs reported that neighborhood children were told to stay away from their child, resulting not only in isolation for the child but also feelings of shame for the parents. Parents of substance-abusing adolescents also experienced shaming interactions when dealing with institutions such as schools, police, and the legal system. Courtesy stigma may disrupt social cohesion through contributing to struggles inside families that have a member who abuses substances. Family members may attempt to distance themselves from a substance-abusing family member in order to distance themselves from courtesy stigma and the shame that can accompany it. It may be the case that much of the behavior described in the literature as enabling or codependent may result from the family’s attempt to avoid the shame of stigma and maintain its identity as a normal family.
Stigma in Treatment Settings
Stigma as a Barrier to Initial Treatment Engagement
The public health implications of untreated substance abuse and dependence are enormous. Despite the proven benefits of substance abuse treatment, only a small fraction of individuals who could benefit ever enter treatment. In 2005, only about 2.3 million of an estimated 23.2 million Americans with substance abuse problems received some form of treatment. Barriers to treatment entry are structural (e.g., location of facilities, lack of qualified personnel, lack of funding) and social (e.g., fear of stigma among those with substance misuse). Stigma contributes to structural barriers when people resist having substance abuse treatment facilities placed in their neighborhoods, thereby limiting access to treatment. This is important because having to travel a longer distance to obtain addictions treatment has been associated with poorer retention. The public is less interested in funding substance abuse treatment compared to treatment for other health or mental health problems, contributing to long waiting lists and prohibitive cost for treatment. Stressful job conditions result in high rates of burnout and job turnover in addictions professionals, resulting in less-experienced counselors and less-integrated, cohesive treatment centers.
Among the social barriers to treatment entry for addiction, probably the most common barrier cited in the literature is stigma. a Across numerous studies, substance-abusing individuals report fear of stigma as a reason for not seeking treatment. For example, Cunningham et al. examined reasons for delaying or not seeking treatment among people with alcohol abuse problems who either self-changed and were in sustained recovery, were still actively abusing, or were currently in treatment. They found that people who were either actively using or self-changed saw treatment as stigmatizing, wanted to avoid the stigma of the label “alcoholic,” and reported that embarrassment and pride were barriers to seeking treatment. All three groups reported relatively similar reasons for avoiding treatment, leaving the authors to conclude that “current treatment is stigmatizing and that some alcohol abusers believe that seeking treatment would reflect negatively on them” (p. 352). A study of depressed individuals in Australia found it common to fear that others would think less of them for seeking help and that professionals would respond to them in a condescending manner.
a References 2, 3, 24, 50, 119, 137.
Stigma and Treatment Retention and Outcome
For individuals who are able to overcome barriers and enter treatment, the most stable predictor of positive outcome is length of time in treatment, with studies commonly finding rates of dropout in the first month of outpatient and residential treatment exceeding 50%. Early treatment retention is critical, as data show that early dropouts have equivalent outcomes to those who are untreated, and that more time in treatment is related to better outcomes. Unfortunately, stigma does not only serve as a barrier to treatment entry; stigma also appears to increase when individuals enter treatment, possibly contributing to poorer retention and thus poorer outcomes. The modified labeling theory of stigma in mental illness of Link and colleagues holds that stigma begins to affect people once they have officially received a label from the treatment establishment. A relatively large body of data on seriously mentally ill and dually diagnosed populations supports the hypothesis that entering treatment for a stigmatized condition can result in a labeling process that negatively affects people’s engagement with treatment, psychosocial functioning, and self-concept.
The data on such a stigma-labeling process are less developed in the area of addiction, but some direct data are available to support this view. For example, Semple et al. found that methamphetamine abusers who had been in treatment previously reported higher levels of stigma-related rejection than those who had never been in treatment. Another survey of people in treatment for substance abuse found that people with higher levels of current stigma-related rejection had more previous episodes of treatment and that this relationship remained stable even after controlling for other explanatory variables, such as current severity of addiction, demographics, secrecy coping, and current mental health. Although this evidence suggests that the impact of stigma and the rate of contact with stigmatizing experiences may increase with treatment entry, we know little about how this happens. For example, we know little about whether stigmatizing messages and rejecting experiences primarily come from nonfamily social relationships, close family, employers, media, or treatment staff. Moreover, we do not know if certain sources have greater effects than others, or whether the effect is different for individuals new to treatment versus individuals returning to treatment.
Stigmatizing Attitudes and Behavior of Professional Staff
The therapeutic alliance early in counseling has been shown to be a predictor of engagement and retention in substance abuse treatment. Other data show that negative therapeutic alliances predict deterioration in substance abuse treatment. Thus any actions on the part of substance abuse treatment practitioners that harm the therapeutic alliance are likely to negatively impact retention and treatment outcome among their clients. Health professionals, including addiction counselors, nurses, physicians, and support staff, have been exposed to the same cultural environment that instills stereotyped beliefs in other people. Thus whether they are aware of it or not, providers likely have internalized many of the same stigmatizing beliefs about substance abuse as others in society. Research shows that health care professionals often have moralistic, negative, and stigmatizing attitudes toward substance misuse and believe that substance-abusing individuals are unlikely to recover. For example, one study of mental health support workers in the United Kingdom found that alcohol and drug addiction produced more negative responses to an attitude questionnaire than did other problems or mental illness and that individuals with alcohol and drug problems were mostly likely to be seen as unable to improve if treated.
To the extent that stigmatizing attitudes are expressed by providers, they could negatively affect the alliance, thereby reducing retention and creating poorer outcomes. Similarly, support and nontreatment staff could create a hostile atmosphere for clients, further contributing to reduced retention. Because stigmatizing attitudes tend to have a greater impact in situations in which one group has power over another, stigmatizing beliefs among health care providers may be particularly likely to negatively affect the recovery of those they are trying to help. Some evidence suggests that stigmatizing interactions with providers may be more frequent than expected: one study of methamphetamine abusers found clients’ inability to get along with treatment staff was a major reason for dropout, whereas two surveys of consumers of mental health services found that 19% and 25% of consumers had experienced stigmatizing provider behavior. Data from a qualitative study of alcohol and drug abuse counselors found that counselors largely saw illicit drug use as a failing of the individual that needed to be fixed with drug treatment rather than seeing the larger context, which includes such factors as stigma. In this study, although counselors were generally aware that stigma serves as a barrier to drug treatment, they “did not perceive they as individuals and as treatment workers could perpetuate the same barriers and prejudices” (p. 378).
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