Reduce Stigma

Introductory Paragraph

The term “stigma” is used to represent the complex of attitudes, beliefs, behaviors, and structures that interact at different levels of society (i.e., individuals, groups, organizations, systems) and manifest in prejudicial attitudes about and discriminatory practices against people with mental and substance use disorders. Attention to stigmatizing structures of society, such as laws and regulations, enables examination of prejudice and discrimination against people with mental and substance use disorders. Discriminatory policies and practices can appear to endorse negative social norms and deepen self-stigma.

Stigma often creates barriers for those who need treatment and other critical services from reaching out for assistance. This lack of understanding impacts many people in society. It can be most harmful to those who suffering from SUD and to those who are in early recovery. Reducing stigma and increasing understanding of substance use disorder improves the chance that people with SUD will find the assistance and support that they need. Addressing stigma requires education and breaking down barriers. This is performed by changing attitudes, perceptions, and even language that is used around SUD. Recent research showed that substance use is more stigmatized than obesity and smoking tobacco. To break down the barrier of stigma we need to educate that SUD is a chronic Illness and that the approach for treatment should be the same as heart disease, diabetes, asthma, cancer or other illnesses.

Key Information

SAMHSA’s working definition of recovery states that recovery is “A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.” SAMHSA lists health, home, purpose, and community as essential dimensions of support for a life in recovery. Stigma is a barrier in recovery. When a person with substance use disorder finally reaches out for help, he or she is often met with judgment or unhelpful responses. This is often the result of stigma. Many examples of stigma are not overt, but are more subtle. Stigma comes in the form of language used, pity, disdain, silence, or rejection. Persons with mental health and substance use problems are exposed to an array of stigma components that interact to endanger their mental health. These components include stereotypes, prejudice, and discrimination

Studies have shown that people with substance use disorder experience labeling, shame, and rejection from family members, friends, teachers, co-workers, supervisors, and health care professionals. This stigma can get in the way of the support that people in recovery need -- especially those in early recovery. Outside stigma can become internalized, leading people in recovery to embody and adopt inaccurate beliefs about themselves due to their exposure to external stigmatizing forces.

Individual factors, such as beliefs, play a large role in an individual’s decision about whether to seek treatment. According to Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health “stigma has created an added burden of shame that has made people with SUDs less likely to come forward and seek help.” Research shows that the vast majority of people do not seek treatment because of attitudinal or belief barriers (e.g., lack of perceived need, concerns about stigma, doubts about efficacy).

Types of Stigma. There are five different types of stigma, and each has an impact at both personal and social levels. Understanding and having awareness of the following types of stigma can help to break down barriers and reinvent the road to recovery.

• Self-Stigma. Shame, evaluative thoughts, and fear of enacted stigma -- prevents users from seeking prevention services, testing, and treatment. Stigma also limits employment, school enrollment, housing, and access to social and safety net services.

• Courtesy stigma. This is “stigma by association” and involves public disapproval evoked as a consequence of people associating with a stigmatized group. This may have a negative impact as people may distance themselves to avoid stigma. One example is society blaming the family for an individual's substance use disorder or mental health condition.

• Public stigma is the collective public’s prejudice and discrimination toward a specific group of individuals — in this case, individual's with substance use problems. These negative perceptions cause emotional and behavioral reactivity.

• Structural stigma. These are policies or institutional actions that intentionally or unintentionally restrict the opportunities of those with substance use disorder and mental health conditions. This could include discriminatory behaviors or negative perceptions held by institutional representatives, such as those in criminal justice systems or healthcare settings. This includes both public and private sector polices that restrict opportunities of those with drug dependence.

• Multiple stigma – Also may be referred to as “double stigma” and is prevalent among those who have co-occurring challenges such as mental illness, substance use disorder, homelessness and poverty.

Stigma Around Addiction Treatment. A large number of treatment centers are more focused on unscrupulous levels of profit, rather than on patients. This has led to a degree of stigma associated with even the seeking of treatment. It has become necessary to increase the quality of information about treatment centers for users seeking treatment as well as people who do patient referrals. Education about the following will help in the identification of the most positive treatment centers.

• Lack of Outcomes Data. The measure of substance use disorder treatment effectiveness may be more nuanced than presented by the treatment center's website. For example, if a center says it has a 90% success rate, that most likely refers to the following conditions:
  • A reduction in the frequency of substance use during drug rehab treatment
  • A reduction in the amount of the substance being used during drug rehab treatment
  • Successful sobriety for a relative period of time (i.e. self-reported sobriety among patients between 3 and 6 months after treatment)
• Unbranded Drug Rehab Websites. Some facilities have created unbranded websites to attract additional web traffic. These websites often try to appear like an independent source verifying that one rehab center may be better than another, when in reality that website was created by a rehab center.
• Drug Rehab Centers: Some Claim to Be Experts at Everything
• Patient Brokering. This illegal practice occurs when "body brokers" make money by recruiting addicts for unethical and unscrupulous treatment facilities
• Rampant Urinalysis Testing and Lab Abuse. Some sober homes around the country make money by recruiting people for the intensive outpatient programs (IOPs) that take place at drug rehab centers. These centers charge millions of dollars in fees to insurance companies for drug urinalysis performed on patients in IOPs.

Reducing Stigma

Those speaking and writing about mental health and addiction should strongly consider the language they use when describing those struggling with those issues. People-first language or person-centric language can influence whether the material produced is further stigmatizing to people. The new edition of the Associated Press style book recommends people first phrasing with the goal of separating the person from the disease. The Addiction Technology Transfer Center (ATTC) has specific suggestions for stigma-reducing language:

• Call it what it is: substance use disorder (or alcohol use disorder, cocaine use disorder, etc.) or substance dependence (or alcohol dependence, drug dependence, etc.). In a non-clinical environment, addiction is also acceptable.

• Use "people first" language and refer to people with substance use disorder, people with drug dependence, people with addiction.

• Avoid negative terms like addict, junkie, wino, boozer, drug fiend, and bum.

Regarding stigma specifically associated with MAT, the National Alliance for Medication Assisted Recovery recommends the following:

⦁ Speak publicly about the productive lives led by MAT patients

⦁ Establish contact with elected and appointed officials

⦁ Attend community meetings

⦁ Prepare and distribute educational material

⦁ Participate in media interviews

⦁ Create a unified voice to reach the public on all issues of concern to MAT patients

Relevant Research

A 2014 literature review of programs for reducing stigma found that online education programs and face-to-face education programs were equally effective in reducing personal stigma (an individual's own attitude towards people with mental illness), but neither was effective in reducing self-stigma. Other research has shown that therapeutic interventions such as group-based Acceptance and Commitment Therapy (ACT) and vocational counseling produce positive outcomes for substance users suffering from self-stigma.

Resources for research regarding reducing stigma include:

• Ending discrimination again people with mental and substance use disorders: The Evidence for Stigma Change
• The effectiveness of interventions for reducing stigma related to substance use disorders: a systematic review 

Impactful Federal, State, and Local Policies

SAFE Solutions is an ever-growing platform.  Currently limited information is readily available for this section.  SAFE Project is dedicated to providing communities with the most relevant and innovative materials.  We will continue to regularly monitor and make updates accordingly with community input and subject matter expert collaboration.  Please check back soon.

Available Tools and Resources

The following organizations, associations, and agencies provide information on stigma, stigma prevention, or developing prevention campaigns. Some of the organizations that provide information on stigma may focus on mental health but also address substance abuse. Similarly, some of the resources on conducting prevention campaigns focus on substance abuse prevention rather than stigma prevention. However, the principles and processes employed by substance abuse prevention campaigns are applicable to stigma prevention campaigns.

Anti-Stigma Toolkit: Guide to Reducing Addiction-Related Stigma is provided by the Addiction Technology Transfer Center (ATTC) Network which is funded by SAMHSA. The ATTC Network is a nationwide, multidisciplinary resource for professionals in the addictions treatment and recovery services field, the ATTC Network raises awareness of evidence-based and promising treatment and recovery practices, builds skill to prepare the workforce to deliver state-of the-art addictions treatment and recovery services and, changes practice by incorporating these new skills into every use for the purpose of improving addictions treatment and recovery outcomes.

The Advertising Council The Ad Council produces, distributes, promotes, and evaluates public service communications programs. It provides information, resources, and assistance to community groups about public service campaigns.

The Anti-Stigma Project fights stigma by raising consciousness, facilitating ongoing dialogues, searching for creative solutions, and educating all participants within or connected to the behavioral health community, including consumers, family members, providers, educators, and administrators. They offer online trainings regarding Stigma reduction. The Distorted Perception's initiative is a public education campaign that was created by the Anti-Stigma Project to provide facts, questions and resources to help our community understand the stigma related to mental illness and addictions.

The Centre for Addiction and Mental Health (CAMH) Addictions Program CAMH is Canada’s largest mental health and addiction teaching hospital. CAMH combines clinical care, research, education, policy development and health promotion to help transform the lives of people affected by mental health and addiction issues.

Community Anti-Drug Coalitions Of America (CADCA) Since 1992 Community Anti-Drug Coalitions of America (CADCA) has been training local grassroots groups, known as community anti-drug coalitions, in effective community problem-solving strategies, teaching them how to assess their local substance abuse related problems and develop a comprehensive plan to address them.

Drugabuse.gov has provided “Words Matter - Preferred language when talking about addiction." It provides a table of stigma reducing language to act as a guide when talking about those with SUD and in recovery.

The Higher Education Center For Alcohol, Drug Abuse, And Violence Prevention Education Development Center, Inc. Funded by the U.S. Department of Education, the Higher Education Center provides support to all institutions of higher education in their efforts to address the problems related to alcohol and other drug abuse and violence.

Mental Health America Mental Health America (formerly known as the National Mental Health Association) is the country’s leading nonprofit dedicated to helping ALL people live mentally healthier lives. MHA represents a growing movement of Americans who promote mental wellness for the health and wellbeing of the nation – every day and in times of crisis.

National Alliance For The Mentally Ill (NAMI) The National Alliance for the Mentally Ill is a nonprofit, grassroots, self-help, support, and advocacy organization of consumers, families, and friends of people with mental health problems. It provides education, supports increased research funding, and advocates for adequate health insurance, housing, rehabilitation, and jobs.

National Mental Health Consumers’ Self-Help Clearinghouse The Clearinghouse was the first national technical assistance center founded and run by individual's diagnosed with mental health conditions. It is peer-run national technical assistance and resource center that fosters recovery, self-determination, and community inclusion. The Clearinghouse serves individuals with lived experience of a mental health condition, peer-run service and advocacy organizations, family members, mental health professionals and service providers, policy makers, and the public.

Stop Stigma Now A campaign to counteract the stigma and resources to help stop the stigma and prejudice directed at both the treatment and the patients. They provide a resource for preferred vs. non-preferred language and a guide to using person centric language.

Substance Abuse And Mental Health Administration SAMHSA is a Federal Government agency that seeks to target effectively substance abuse and mental health services to the people most in need and to translate research in these areas more effectively and more rapidly into the general health care system.

Promising Practices

Best practices and barriers to Engaging People with Substance Use Disorders in Treatment This guide provides stigma reducing best practices such as: “Co-location of SUD counseling and other services with primary care reduces the stigma of accessing a facility identified as treating SUDs, catches members in locations where they are more comfortable, and permits improved coordination between physical and behavioral health care.”

SAFE Project SAFE Project believes there’s No Shame in getting help or in talking about mental health and addiction. The No Shame Pledge  supports the ability to get help without judgement and acknowledges commitment to saving lives by fighting the stigma. 

State Without Stigma Video A public service announcement surrounding reducing stigma.