Published: November 8, 2021
By: Sandra McNeil
As a new MSW graduate, I started my first position in a community addiction agency providing counseling services to people seeking support with their substance use and other concerns (e.g., gambling). Despite important shifts in how we understand and treat mental health and addiction issues, such as recovery oriented practice and efforts to reduce stigma, my anecdotal observations indicated that people with substance use concerns are frequently disrespected, pathologized, and discriminated against, sometimes seemingly more so than people with mental health issues. This led me to do some research about how substance use stigma is understood and addressed, and to promote its reconceptualization through a social justice lens (McNeil, 2021).
How substance use stigma is conceptualized has implications for public health research, policy and practice. Stigma has been widely studied and most researchers make reference to Erving Goffman’s sociological conceptualizations of stigma based on his groundbreaking book, Stigma: Notes on the Management of Spoiled Identity published in 1963. His description of people with stigma as “not quite human” (p. 3-5) may have contributed to the construction of negative stereotypes related to difference. A social psychological analysis of how people think, feel, and behave in relation to stereotypes, prejudice, and discrimination has also been used to identify different types of stigma such as self/internalized stigma, public/social stigma, enacted stigma, and structural stigma (Jones & Corrigan, 2014). Much of the substance use stigma research tends to focus on stigma at individual levels, often neglecting broader sociocultural, economic and political factors that create and perpetuate social inequality, although attention to structural stigma in mental health and addiction is increasing (Livingston, 2020). Particularly alarming, however, are underlying assumptions that stigma may be a useful mechanism to prevent unhealthy behaviours (Bayer & Fairchild, 2015).
Studies related to self-stigma indicate that people with substance use issues often experience blame, shame, and low self-esteem that interfere with their treatment and recovery (Da Silveira et al., 2018). This has negative consequences for their mental and physical health, and their social and occupational functioning (Can & Tanriverdi, 2015). From a societal perspective, the general public often perceives people with substance use issues as deficient, irresponsible, and lazy (at best), criminal, violent, and dangerous (at worst) (Nieweglowski et al., 2018). As these public perspectives circulate in society, they permeate individual and collective minds, perpetuating and reinforcing negative stereotypes. Responses to self and public stigma tend to focus on changing individual attitudes, beliefs, and behaviours. People with substance use issues are encouraged to seek treatment, develop coping skills to manage stigma, and improve their mental health and self-esteem (Lloyd, 2013). Anti-stigma initiatives are designed to educate the public about stigmatizing assumptions, language, and practices. People are encouraged to speak out against stigmatization and cultivate positive contacts with the affected population to dispel myths. Despite the value of these understandings and approaches to substance use stigma, they do not address structural contributors.
Structural stigma occurs when people with substance use issues are denied opportunities for employment, education, and housing, and penalized by the criminal justice system (Buchanan & Young, 2000; Radcliffe & Stevens, 2008). Several studies indicate that structural stigma is also perpetrated by health care and service providers (Bielenberg, 2018; Chang et al., 2016; Earnshaw et al., 2013). Recommendations call for increased funding and services to attend to the social determinants of health, greater decriminalization and harm reduction policies, and additional education and training for service providers.
The individualized focus on substance use stigma was interesting to me, especially since other types of stigma related to mental illness and HIV have taken a broader structural analysis based on human rights, social inequities, and intersectional diversity (Parker & Aggleton, 2003; Pescosolido et al., 2010). A structural perspective of substance use stigma may be limited because any harms someone may experience related to substance use are still frequently considered a personal choice. In the current political context of neoliberalism, individual choice and personal responsibility are paramount. People are expected to adopt “healthy” lifestyles (i.e., eat properly, exercise regularly, limit or abstain from alcohol and other drugs) and if they fail to do so, they are frequently blamed and stigmatized. This reductionist social control perspective reflects power operations that reinforce norm compliance to maintain a healthy capitalist labour force.
If substance use issues are truly considered under the umbrella of mental health/illness, why do we continue to blame and punish people for their “poor choices” and “bad behaviours”? Is there another way to think about substance use? My dissertation research focused on substance use recovery and stigma in rural communities. I use the term ‘substance use issues’ to refer to social, economic and/or legal issues resulting from the use of alcohol and other drugs, and I avoid terms such as ‘substance dependence’ or ‘substance use disorder’ that may reinforce stigma. As we know, language matters, especially since substance use and stigma are positioned on complex continuums. One of the findings illustrated that people with substance use issues endure monumental losses in terms of housing, employment, education, transportation, family, friends, physical and mental health, dignity, respect, and identity. It begs the question – why? Why do people with substance use issues have to lose so much? Perhaps because social, economic, and political systems and structures are set up in ways that prevent people from getting their basic needs met. It is important to think about substance use stigma as a form of structural violence in which the inequitable distribution of resources causes harm to already marginalized populations – harm that is avoidable (Farmer et al., 2006; Parker, 2012).
However, not all people with substance use issues experience loss, harm, and stigma to the same degree, and not all people who use substances experience problematic substance use or substance use disorder. Processes of stigmatization often depend on which people are using which substances in which contexts (Room, 2005). For example, racialized groups using crack are more stigmatized than upper class white people using powder cocaine (Ahern et al., 2007), intravenous drug use is more stigmatized than non-intravenous drug use (Luoma et al., 2007), and crack is more stigmatized than other illegal substances (da Silveira et al., 2018). This means that substance use stigma must also be understood as a sociocultural construction that privileges white, middle-class norms and fuels social inequality. An intersectional analysis of substance use stigma is needed to better understand the complex interactions among diverse social identities, different levels of stigma, and various types, amounts, frequencies, and methods of substance use.
The conceptual framework I developed is based on an integrated substance use stigma model that connects structural violence, social control, and intersectionality. Structural violence oppresses society from the top down through social, economic, and political policies, while personal and public beliefs that stigma is an effective method of social control operate from the bottom up. These mutually constitutive forces create substance use stigma that permeates society at complex intersections of identity.
Thinking about substance use stigma from this conceptual model may be helpful in promoting research that focuses on structural inequities and human rights rather than on individual blame, deficiency, and responsibility. Public policies developed from a structural analysis of substance use stigma may be less likely to criminalize and penalize people with substance use issues, and more inclined to support increased funding and equitable distribution of resources and services. A structural perspective also challenges policy inaction in which the needs of people who experience substance use stigma are often overlooked (Link & Hatzenbuehler, 2016). The theoretical shift from individual to structural perspectives in research and policymaking may result in fewer practice interventions designed to change people’s substance using behaviours and/or cope with their experiences of stigma, and more interventions designed to change the systems and structures in which stigma exists. Ultimately, how we understand substance use stigma determines how we respond to it.
References
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The views expressed in SURE Blog posts are those of the author(s) and do not necessarily represent the views of the Canadian Public Health Association or Health Canada.
