Re: Breaking The Substance Abuse Grief Stigma
Anastacia Iacono
Committee on the Science of Changing Behavioral Health Social Norms; Board on Behavioral, Cognitive, and Sensory Sciences; Division of Behavioral and Social Sciences and Education; National Academies of Sciences, Engineering, and Medicine. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington (DC): National Academies Press (US); 2016 Aug 3.
This chapter offers a brief overview of what is currently understood about stigma, including influencing factors and consequences of stigma from the level of society as a whole to the experience of people with behavioral health disorders. Targets for change and interventions for changing stigmatizing attitudes, beliefs, and behaviors are discussed in Chapter 4.
Public knowledge and norms about people with mental and substance use disorders have been captured through population-based surveys with components focused on the stigma of mental and substance use disorders as it is reflected in stereotypes, help- or treatment-seeking, and behavioral dispositions.
Results of an analysis of the National Comorbidity Survey-Replication that compared data from the early 1990s and early 2000s showed that stigma associated with mental health treatment decreased, and support among the general public for treatment-seeking increased (Mojtabai, 2007). A survey of states in 2007 and 2009 showed that more than 80 percent of U.S. adults agreed that mental illness treatment is effective; people living in states with higher per capita expenditures on mental health services were more likely to agree that treatment is effective and were more likely to report receiving treatment (Centers for Disease Control and Prevention et al., 2012).
Comparing results of the 1996 General Social Survey (GSS) stigma modules with those of surveys in the 1950s on U.S. attitudes about mental illness stigma showed that public knowledge about mental and substance use disorders increased, specifically as it related to the neurobiological underpinnings of these disorders. There was greater public awareness of the stigma associated with these disorders, but public stigma itself remained high (Pescosolido, 2013; Pescosolido et al., 2010). Results from the 2006 GSS found greater sophistication in the public's knowledge of disorders and treatment than in the 1996 survey administration, but stigma levels for people with mental illness did not decrease over time (Pescosolido et al., 2010).
Finally, a review of studies of public stigma of mental illness, which included studies with variables related to substance use disorders, showed that over time the proportion of Americans who endorse neuroscientific views of schizophrenia and alcohol dependence has grown (Pescosolido, 2013). Americans also have endorsed the use of physicians and prescription medication for these disorders in greater numbers and reported being more willing to discuss behavioral health difficulties with family and friends. However, the persistence of core prejudice factors help explain why increased public knowledge has not decreased public stigma. Core indicators of stigma remain higher for people with schizophrenia and substance disorders than other conditions. Further, the highly stigmatizing public perception of violence as a component of mental illness has not decreased over time.
In this chapter and throughout the report, in discussing stigma we begin with structural stigma and work from it to public stigma and self-stigma. This ordering reflects the committee's views on the relationships among the three levels of stigma and on the importance of addressing structural stigma and its consequences as a means for also reducing public and self-stigma. Societal structures reflect public norms and values, and many of the factors that influence structural stigma are the same as those that influence public stigma. Self-stigma occurs when a person with mental or substance use disorder internalizes negative stereotypes and the public and structural stigma directed at these disorders.
Public perceptions and beliefs about mental and substance use disorders are influenced by knowledge about these disorders, the degree of contact or experience that one has had with people with mental and substance use disorders, and media portrayal of people with mental and substance use disorders, as well as media coverage of tragic events, notably gun violence and suicide (Swanson et al., 2015). Public perceptions are also strongly influenced by social norms concerning the attribution of cause, or blame, for mental and substance use disorders, and the perceived dangerousness or unpredictability of people with these disorders. Race, ethnicity, and culture are embedded in social relationships and as such play a role in shaping attitudes, beliefs, and behaviors.
A biogenic model of the origins of mental and substance use disorders has been applied in an effort to reduce blame and promote positive attitudes about the value of treatment and the possibility of recovery. People with substance use disorders are generally considered to be more responsible for their conditions than people with depression, schizophrenia, or other psychiatric disorders (Crisp et al., 2000, 2005; Lloyd, 2013; Schomerus et al., 2011). Belief that a substance misuser's illness is a result of the person's own behavior can also influence attitudes about the value and appropriateness of publicly funded alcohol and drug treatment and services (Olsen et al., 2003).
There is a lack of empirical evidence supporting the stigma-reducing benefits of a neurobiological conceptualization of psychiatric illness (Trujols, 2015). Although some research suggests that attributing mental illness to biological causes may reduce the blame placed on individuals for their behavior (Rosenfield, 1997), other research has shown that attributing behavior to a genetic cause can increase perceptions of the difference of people with the disorder, and of the persistence, seriousness, and possible transmissibility of mental illness (Phelan, 2005). Overall, promulgation of the brain disease model of addiction does not appear to have reduced public stigma about substance use disorders and may decrease perceptions of self-efficacy and ability to cope among people with behavioral health disorders (Trujols, 2015).
Americans are more likely to believe in the dangerousness of people with mental illness than are citizens of other developed, industrialized nations (Jorm and Reavley, 2014). In a recent national survey, four in ten Americans believed that children and adolescents with depression were likely to be violent, a finding that may be related to media coverage of school shooting incidents (Pescosolido, 2013). Stereotypes of violence and unpredictability are associated with higher levels of public stigma toward people with mental illness (Martin et al., 2000, 2007; Perry, 2011; Phelan et al., 2000). People with substance use disorders are considered even more dangerous and unpredictable than those with schizophrenia or depression (Schomerus et al., 2011). In a survey conducted in the United States (Link et al., 1997), a vast majority of respondents considered it likely for a cocaine- or alcohol-dependent person to hurt others. People are less likely to endorse the stereotype of violence if they have had direct contact with people who have mental and substance use disorders and have not experienced violent acts by people with these disorders (Jorm and Reavley, 2014).
Stereotypes of dangerousness can influence public policy in terms of restricting the rights of persons with behavioral disorders (Pescosolido et al., 1999). In the current context of the increasing frequency of mass shootings in the United States (Blair and Schweit, 2013), beliefs about the dangerousness of persons with mental illness and substance use disorders have come to the forefront in public policy debates. To inform these debates, a review of epidemiological findings related to mental illness, gun violence, and suicide found that there is a greater relative risk of violence in people with mental illness than those without mental illness, but the risk is actually very small. The risk of violence is greater for people with schizophrenia, bipolar disorder, co-occurring substance use disorder, and those exposed to certain socioeconomic factors, such as poverty, crime victimization, early life trauma, and a high neighborhood crime rate (Swanson et al., 2015). People with substance use disorders and antisocial personality disorders have a higher risk of violence than people with other psychiatric disorders (Fazel et al., 2009). The risk of suicide, as another form of violence, is increased by concurrent substance use; symptoms, such as hopelessness and depression; psychotic disorders; bipolar disorder; and environmental factors, such as access to guns and media reporting of suicide (Swanson et al., 2015). Swanson and colleagues point to the gaps in the knowledge base on the relationship between behavioral disorders, violence, suicide, and guns, as well as to the gaps in knowledge on effective policies to reduce gun violence and suicide.
Knowledge about mental and substance use disorders can positively influence public norms, yet there is evidence that reframing these disorders as brain diseases produces mixed results on people's attitudes and behavior toward people with mental and substance disorders. As noted above, public education campaigns that frame mental and substance use disorders as brain diseases can have unintended consequences, including increased perception of difference and disbelief in the likelihood of recovery (Pescosolido et al., 2010; Schomerus et al., 2012; Trujols, 2015).
People with substance use disorders, in particular, are viewed by the public as weak-willed (Schomerus et al., 2011) although evidence shows that they are as likely to adhere to treatment as people with other chronic medical conditions, such as hypertension or diabetes (McLellan et al., 2000). Unfortunately, and in spite of efforts to educate the public, this misperception has increased over time according to the findings from national surveys in 1996 and 2006 (Pescosolido et al., 2010). Media portrayals of people with untreated and symptomatic substance use disorders, rather than depictions of those on a path to recovery, may be a factor in maintaining or increasing negative stereotypes and stigmatizing attitudes and beliefs about people with substance use disorders (McGinty et al., 2015).
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