Stigma as a Barrier to Treatment and Recovery
Stigma, according to the UK Drug Policy Commission, is a ‘‘stain or attribute’ marking out someone as unacceptable. It leads to prejudice and discrimination.’ [1]
Stigma can be contrasted with disapproval, which relates to someone’s actions. Stigma refers more to assumptions based on someone’s characteristics. Stigmas are engrained, difficult to dislodge, and frequently cause ‘prejudice and discrimination’, as the above definition states.
In the context of substance use, stigma is a serious problem. This is due largely to the belief that drug addiction is a choice, and given the negative consequences of drug addiction, a very bad choice indeed.
However, there is a lot of scientific evidence to suggest that drug addiction is a complex phenomenon, which resembles a disease rather than a chosen way of life. If it is true that drug addiction is more akin to a disease, then we need to show more compassion towards people with substance use disorders (SUDs) and drug use disorders (DUDs).
How prevalent is stigma?
The UK Drug Policy Commission surveyed attitudes towards drug addiction and mental health, and the results showed just how far there is to go to the UK in terms of overcoming stigma. When presented with the statement that ‘People with a history of drug dependence are a burden to society’, 47% agreed. When asked the same question with regards to mental illness, only 8% agreed.
The stark contrast here could be due to the perception that addiction is a choice, whereas mental illness is a disease that cannot be helped. As stated above, this perception does not tally with the scientific evidence.
One study by Jason B. Luom found that ‘substance misuse appears to be at least as stigmatized as psychological disorders such as depression, schizophrenia, or borderline personality disorder’. [2] If the UK Drug Policy survey is to be believed, substance misuse may even be more stigmatized than mental illness, although of course certain mental illnesses carry a greater stigma than others.
Whatever the exact level of stigma towards substance use and addiction, it is clear that there is still significant progress to be made in order to destigmatise this condition.
There were, according to Public Health England, 268,251 adults in contact with drug and alcohol services between April 2018 and March 2019. [3] More important, arguably, is the percentage of people with substance use disorders who are not in treatment.
According to the same statistics, 46.4% of opiate users were not in treatment in the year 2018 to 2019; for crack users, that figure stood at 40.3%. [4] Given how dangerous and destructive these drugs can be, it is very concerning that so many users of these drugs are not in treatment. Serious questions need to be asked about why that is the case, and what barriers could be stopping people from accessing treatment.
What causes stigma?
There are many ways in which people can encounter stigma and internalise it. We’ve listed a few of them below:
- The media. The media hold a huge influence on people’s perceptions. Whether a newspaper is sympathetic or judgemental towards drug users can have a massive impact on whether the general public feels sympathy towards drug users. Since the research done by the UK Drug Policy Commission, the government has advised journalists to adopt more sympathetic language towards drug users, replacing words like ‘junkie’ with ‘drug user’, and removing references to ‘drug abuse’, ‘addict’ and so on. We’ll talk about this in more depth later on in this post
- Negative stereotypes about drug users and lack of awareness. If you are frequently told that drug users are criminals and a burden to society, and you do not have any information to disprove these assertions, you are liable to form the same opinion. What makes this source of stigma especially difficult to counter is the fact that drug users are more involved with crime, especially acquisitive crime, and treatment for addiction does cost the UK government a lot of money. [5] [6] So there is some justification for these negative views of drug users. However, we have to come back to the idea that addiction is not a matter of choice, and people’s circumstances, family history, mental health and predisposition towards developing an addiction all play a part in whether they develop a SUD
- Prejudices towards people of a certain class or background. Unfortunately, addiction is often tied up with poverty and deprivation. The rates of substance use among the lowest-earning households in the UK are significantly higher than among any other group. [7] This means that stigma towards low-earning individuals is often combined with stigma towards substance users
Language and stigma
Another big issue with regards stigma is the use of language. In recent years, we have seen an overhaul of the way in which we refer to minorities and disadvantaged people. This has had a largely positive effect, in areas such as race, disability, gender, sexuality, mental health and more.
It could be argued, however, that addiction has lagged behind other such areas. Whereas the word ‘retard’ has been almost entirely phased out – and for good reason – terms like ‘substance abuser’, ‘addict’, ‘junkie’ are still in common parlance.
There is evidence to suggest that this sort of language causes a fair amount of harm. One well-known study by Dr John Kelly presented participants with two vignettes, one of which used terms like ‘substance abuser’, whereas the other used more neutral terms like ‘having a substance use disorder’.
The results were fascinating. Participants were found to be more likely to agree with the idea that the person in the first vignette was ‘personally culpable’ for their problems with substances, and that punitive measures should be taken against them. This suggests that the language we use to talk about people with substance use disorders is important, and can play a role in how these people are treated.
Is the language we use to talk about people with SUDs becoming more neutral? Yes, but we are still in the early stages of this process. This article by Michael Botticelli, former Director of National Drug Control Policy for the Obama Administration, talks about how his department-issued guidance to federal agencies to get them to use more appropriate language when talking about drug users.
It also mentions the fact that this was picked up by the AP Stylebook, a guide for journalists. This guide now warns people to ‘Avoid words like alcoholic, addict, user, abuser, junkie, drunk or crackhead.’ [9]
The same is happening in the UK. The UK Drug Policy Commission published similar guidance, warning journalists to be more careful in the way they refer to people with SUDs. It said:
While it is true that addicts are not called “junkies” with the regularity they used to be, the word still does appear. But it is the heavily negative, critical and/or judgmental tone used to refer to people with drug addictions that are most likely to lead to their stigmatisation. [10]
It seems that language is beginning to improve with regards drug use. Hopefully, this will lead to a reduction in stigma, and with it a reduction in the negative consequences of stigma.
Types of stigma
Stigma is categorized into two main forms: public stigma, which is stigma shown by the general population towards a certain group, and self-stigma, which is internalised stigma on the behalf of that group. [11]
There is also perceived social stigma, which results from public stigma. Perceived social stigma is when a marginalised person, in this case, someone with a SUD, believes that they will be viewed and treated in a negative way by society.
This has negative consequences especially when it comes to getting treatment. In fact, some have argued that perceived social stigma constitutes a ‘systematic barrier’ to treatment. [12] Studies have found that medical staff in primary care do not feel well-equipped to deal with patients with SUDs, and may have negative biases towards this population. [13]
This could play a part in the unwillingness of parts of the population who have SUDs to seek treatment. It may be that the attitude of staff in primary care does not translate into actual discrimination, but subtle reactions to service users with SUDs that show a negative feeling might dissuade these people from getting further treatment. It may also translate into self-stigma.
Self-stigma is, as stated above, stigma that gets internalised by people with SUDs, which translates into feelings of low self-worth. It then makes them less likely to get treatment, since they feel that it is pointless. After all, they will only relapse again as soon as they leave treatment. This stigma is especially damaging and needs to be combatted at all costs. People with SUDs need to be told that they can overcome their problem with substances and that they are valuable members of society.
That being said, it may be easier to combat public stigma than self-stigma. By the time stigma has been internalised it becomes harder to dislodge. We need to push for more sympathetic representations of people with SUDs in the media, and overcome negative attitudes in the general population, in order to stop this stigma from being internalised.
Impact of stigma on people with substance use disorders
We’ve already touched on one area in which stigma might have an impact on people with SUDs, in terms of their willingness to seek treatment. But are there any other ways in which stigma affects people with addiction issues? We’ve listed a few below.
- Mental health. The belief that one is worthless, a criminal, beyond saving or a burden on society is bound to have an impact on one’s mental health. It is very difficult to measure something like this, but it seems likely that someone who feels stigmatised might be more prone to conditions like depression. This in turn leads to worse physical health, more drug abuse and further strain on relationships
- Feelings of alienation and marginalisation. Someone who feels the weight of public stigma is much more likely to feel that they are unwanted by society. This might lead to feelings of isolation; it might also make someone more likely to commit a crime
- Unwillingness to overcome substance problems. If you believe that society has a negative view of you and your lifestyle and that you are seen as nothing more than a ‘burden’, that is unlikely to make you want to change. If, however, you are told that you can contribute to society and that you are valued, that might make you more willing to seek treatment and overcome your SUD. Feeling valued – the opposite of stigmatised – might be the key to reaching out to people with SUDs so that they actually want to stop using substances
Stigma and treatment
The 2016 National Survey on Drug Use and Health found that ‘twenty-five per cent of respondents said that fear of negative opinions among neighbours and friends and their employer were significant barriers to seeking care.’ [14]
If stigma makes people less likely to get treatment, what are some of the consequences of that? What does it mean for treatment providers, society in general and people with SUDs themselves?
- Treatment providers. Treatment providers need to be aware of the effect of stigma and work hard to overcome it. Telling staff to be extra-warm and welcoming towards service users might be one strategy to consider. Warning them against using pejorative language is another thing they should definitely do.
- If there are large numbers of people who meet the criteria for a SUD who are not getting treatment, because of stigma or another reason, that constitutes a major problem for society. Untreated SUDs cost the government money, in terms of lost productivity, health care and crime. It also has an impact on people’s relationships, as living with someone who has untreated SUD can be challenging
- People with SUDs. Having an untreated SUD is very difficult for the person themselves. It may have an impact on health, mental health, finances, relationships and more. It is essential that we overcome stigma in order to reduce the barriers stopping people from getting treatment
Pushing back against stigma
The process of dispelling stigma around substance use is a complex, multi-faceted one that requires individual action, changes in language and changes in government policy. Without going into too much detail, here are a few ideas about how to get rid of stigma.
- As an individual. Show compassion towards people with SUDs, and challenge those who denigrate or make false claims about these people. Use appropriate language. Treat people with dignity. Educate yourself about addiction
- Changes in language. Everyone – from the man in the street to the media, to people in government – needs to use more appropriate language to talk about addiction. As we have seen, there are real consequences to using charged terms like ‘substance abuser’, ‘junkie’ and so on. Try to use neutral language where possible
- Governments. Campaign for better treatment towards people with SUDs. Invest n good quality treatment. Make sure legislation is fair. And take heed of the advice given out by the UKDPC in their research on drug use and stigma
There is some cause for optimism. We are witnessing a period in history in which stigma towards people with SUDs is being gradually eroded. In ten or twenty years’ time we may see a complete attitude shift. This will have profoundly positive effects on the portion of the population who suffer from SUDs.
References
[1] UK Drug Policy Commission, ‘Getting Serious about Stigma: the problem with stigmatising drug users’, Dec 2010.
https://www.ukdpc.org.uk/wp-content/uploads/Policy%20report%20-%20Getting%20serious%20about%20stigma_%20the%20problem%20with%20stigmatising%20drug%20users.pdf
[2] Jason B. Luoma, Substance Use Stigma as a Barrier to Treatment and Recovery, Aug 2010.
[3] Public Health England, Adult substance misuse treatment statistics 2018 to 2019: report.
https://www.gov.uk/government/publications/substance-misuse-treatment-for-adults-statistics-2018-to-2019/adult-substance-misuse-treatment-statistics-2018-to-2019-report
[5] Trevor Bennett et al. ‘The Statistical association between drug misuse and crime: A meta-analysis’, 2008. https://www.sciencedirect.com/science/article/abs/pii/S1359178908000037
[6]
‘How addiction took hold of the UK – and cost the NHS millions’, Rachel Williams, The Guardian.
https://www.theguardian.com/healthcare-network/2018/may/24/addiction-took-hold-uk-cost-nhs-millions
[7] Office for National Statistics, ‘Drug misuse in England and Wales: year ending March 2020’ https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/drugmisuseinenglandandwales/yearendingmarch2020#personal-characteristics
[8] Dr John Kelly, ‘Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms’, 2009.
https://pubmed.ncbi.nlm.nih.gov/20005692/
[9] Michael Botticelli, ‘Stigma and Substance Use Disorder: Breaking Down Barriers to Treatment and Sound Public Policy’, 2019.
https://obamawhitehouse.archives.gov/blog/2017/01/13/changing-language-addiction
[10] UKDPC, Representations of drug use and drug users in the British press, ‘Dealing with the stigma of drugs: a guide for journalists’, https://www.ukdpc.org.uk/wp-content/uploads/dealing-with-the-stigma-of-drugs.pdf
[11] Jason B. Luoma, Substance Use Stigma as a Barrier to Treatment and Recovery, Aug 2010.
[12] R Hammarlund et al., ‘Review of the effects of self-stigma and perceived social stigma on the treatment-seeking decisions of individuals with drug- and alcohol-use disorders’, 2018.
[13] Van Boekel et al., ‘Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review.’
https://pubmed.ncbi.nlm.nih.gov/23490450/
[14] Survey on National Drug Use and Health, 2016. https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2016/NSDUH-DetTabs-2016.pdf
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